Common use of PARTICIPANT’S ACCEPTANCE Clause in Contracts

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option and agrees to the terms and conditions thereof. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: NOTICE OF STOCK OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am the holder of an Incentive Stock Option granted to me under the Catabasis Pharmaceuticals Inc. (the “Company”) Amended and Restated 2008 Equity Incentive Plan, as amended to date, on [ ] for the purchase of [ ] shares of Common Stock of the Company at an exercise price of $[ ] per share. I hereby exercise my option to purchase shares of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation of the Securities Act of 1933 (the “Securities Act”), or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have not been registered under the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)

Appears in 2 contracts

Samples: Incentive Stock (Catabasis Pharmaceuticals Inc), Incentive Stock (Catabasis Pharmaceuticals Inc)

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PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2021 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2021 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by HV Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the HV Bancorp, Inc. 2021 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase shares of common stock of the Company (“Common Stock”) for a purchase price of $ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $ , in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any required tax withholding). ___ Selling shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act1933 prior to your exercise of such Option. Date: , (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)Participant’s signature

Appears in 2 contracts

Samples: Non Qualified Stock Option Award Agreement (HV Bancorp, Inc.), Incentive Stock Option Award Agreement (HV Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2014 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2014 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: Schedule The above form of Stock Option Agreement was signed by Xxxx X. Xxxxxxxxx, Chairman and Chief Executive Officer (400,000 shares), and Xxxxxx X. Xxxxx, President and Chief Operating Officer (278,000 shares). EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: (BY EMPLOYEE) I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Northfield Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Northfield Bancorp, Inc. 2014 Equity Incentive Plan (the “Plan”) referred to therein, and notify you of my desire to purchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $_______ per share. I wish to pay the purchase price by (check one or more, as amended applicable): [Any payment to datebe delivered must accompany this Notice of Exercise of Option] ___ Cash or personal, on certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A “net settlement” of the Option whereby I direct the Company to withhold a sufficient number of shares to satisfy the purchase price. [ ] for Withhold a sufficient number of shares to pay minimum required taxes [ ] Calculate minimum required withholding and I will submit payment. ___ A check (personal, certified or cashier’s) in the sum of $_______ and stock of the Company with a fair market value of $______, in full payment of the purchase price.* ___ Please sell ______ shares from my Option shares through my broker in full/partial payment of [ ] the purchase price. If my broker requires additional forms in order to consummate this “broker cashless exercise,” I have included them with this election. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, the Company or any rule transfer agent may require an opinion of counsel that such resale or regulation under distribution would not violate the Securities ActAct of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having been exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I have had such opportunity will keep the shares that I already own and treat them as if they are shares acquired by the option exercise. In addition, I have deemed adequate will receive additional shares equal to obtain the difference between the shares I constructively exchange and the total new option shares that I acquire. EXHIBIT B EXAMPLE: Assume the employee is granted 500,000 Option Awards on July 1, 2014. The Option Award vests at the rate of 20% per year (i.e., 100,000 shares per year) commencing one year from representatives the date of grant. Also assume each director is granted 100,000 Option Awards on July 1, 2014 and that each director’s awards vest at the rate of 20% per year (i.e., 20,000 shares per year) commencing one year from the date of grant. Further assume that the employee resigns as an employee, effective December 31, 2016, but continues in the service of the Company such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase a member of the Shares and to make an informed investment decision with respect to such purchaseBoard. I can afford a complete loss At the time of the value employee’s resignation, the employee would have vested in an aggregate of 200,000 Option Awards (on July 1, 2015 and July 1, 2016). The employee’s resignation occurs six months into the third vesting year. Accordingly, on July 1, 2017, the former employee would vest in 60,000 Option Awards, calculated as follows: 100,000 Option Awards (employee grant) x 6/12 (July – December) = 50,000 20,000 Option Awards (director grant) x 6/12 (January through June) = 10,000 Further, the former employee would forfeit 80,000 Option Awards from each of the Shares installments vesting July 1, 2018 and am able to bear July 1, 2019. The effect of this is that the economic risk former employee would vest in a number of holding such Shares for Stock Options during the two years in which he performed no services as an indefinite period. I understand that (i) the Shares have not been registered under the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available employee equal to the public, and same number of Stock Options in which the other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)non-employee directors vest for such years.

Appears in 2 contracts

Samples: 2014 Equity Incentive Plan (Northfield Bancorp, Inc.), 2014 Equity Incentive Plan (Northfield Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended Plan and Restated 2008 Equity Incentive Plan, as amended to datePlan Prospectus. PARTICIPANT Date: By: [ ] Address: EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: (BY OUTSIDE DIRECTOR) I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Northfield Bancorp, Inc. (the “Company”) Amended and Restated 2008 Equity Incentive Plan, as amended ” I wish to date, on [ ] for pay the purchase price by (check one or more): [Any payment to be delivered must accompany this Notice of [ Exercise of Option] ___ Cash or personal, certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A “net settlement” of the Option whereby I direct the Company to withhold a sufficient number of shares to satisfy the purchase price. ___ A check (personal, certified or cashier’s) in the sum of $_______ and stock of the Company with a fair market value of $______, in full payment of the purchase price.* ___ Please sell ______ shares from my Option shares through a broker in full/partial payment of the purchase price. If my broker requires additional forms in order to consummate this “broker cashless exercise,” I have included them with this election. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by xxxxxxxxxx shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having been exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Equity Incentive Plan (Northfield Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended Plan and Restated 2008 Equity Incentive Plan, as amended related prospectus have been provided or made available to datethe Participant. PARTICIPANT Date: By: [ ] Address: ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Eureka Homestead Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Eureka Homestead Bancorp, Inc. 2020 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $______ per share. ​ I wish to pay the exercise price by (check on or more): ​ ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a Fair Market Value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, whereby I direct the Company to withhold a sufficient number of shares to satisfy the exercise price obtained on exercise in payment of the exercise price of the Option (and, if applicable, any tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution ​ Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. ​ ​ Participant’s signature ​ ​ ​ * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Incentive Stock Option Agreement (Eureka Homestead Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2017 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2017 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: ________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals Inc. by Cincinnati Bancorp (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Cincinnati Bancorp 2017 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act1933 prior to your exercise of such Option. Date: ____________, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act_____. Very truly yours, (Signature)_________________________________________ Participant’s signature

Appears in 1 contract

Samples: Equity Incentive Plan (Cincinnati Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2013 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2013 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: ___________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: (BY OUTSIDE DIRECTOR) I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Madison County Financial, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Madison County Financial, Inc. 2013 Equity Incentive Plan (the “Plan”) referred to therein, and notify you of my desire to purchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $_____________ per share. I wish to pay the purchase price by (check one or more): [Any payment to be delivered must accompany this Notice of Exercise of Option] ___ Cash or personal, certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A “net settlement” of the Option whereby I direct the Company to withhold a sufficient number of shares to satisfy the purchase price. ___ A check (personal, certified or cashier’s) in the sum of $_______ and stock of the Company with a fair market value of $______, in full payment of the purchase price.* ___ Please sell ______ shares from my Option shares through a broker in full/partial payment of the purchase price. If my broker requires additional forms in order to consummate this “broker cashless exercise,” I have included them with this election. I understand that after this exercise, ____________ shares of Common Stock remain subject to the Option, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby represent that it is my intention to acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Section 2(11) of the Securities Act of 1933) the shares you acquire through this Option exercise, the Company or transfer agent may require an opinion of counsel that such resale or distribution would not violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having been exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and treat them as if they are shares acquired by the option exercise. In addition, I will receive additional shares equal to the difference between the shares I constructively exchange and the total new option shares that I acquire. OUTSIDE DIRECTOR EXHIBIT B ACKNOWLEDGMENT OF RECEIPT OF SHARES I hereby acknowledge the delivery to me by Madison County Financial, Inc. (the “Company”) or its affiliate on _____________________________, of stock certificates for ____________________ shares of common stock of the Company purchased by me pursuant to the terms and conditions of the Stock Option Agreement and the Madison County Financial, Inc. 2013 Equity Incentive Plan, as amended applicable, which shares were transferred to date, me on [ ] for the purchase of [ ] shares of Common Stock of the Company at an exercise price of $[ ] per share. I hereby exercise my option to purchase shares of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation of the Securities Act of 1933 (the “Securities Act”), or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company’s stock record books on ____________________. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have not been registered under the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)Date:__________________ _______________________

Appears in 1 contract

Samples: Equity Incentive Plan (Madison County Financial, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2013 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2013 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: (BY OUTSIDE DIRECTOR) I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals Inc. by Charter Financial Corporation (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Charter Financial Corporation 2013 Equity Incentive Plan (the “Plan”) referred to therein, and notify you of my desire to purchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $_____________ per share. I wish to pay the purchase price by (check one or more): [Any payment to be delivered must accompany this Notice of Exercise of Option] ___ Cash or personal, certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A “net settlement” of the Option whereby I direct the Company to withhold a sufficient number of shares to satisfy the purchase price. ___ A check (personal, certified or cashier’s) in the sum of $_______ and stock of the Company with a fair market value of $______, in full payment of the purchase price.* ___ Please sell ______ shares from my Option shares through a broker in full/partial payment of the purchase price. If my broker requires additional forms in order to consummate this “broker cashless exercise,” I have included them with this election. I understand that after this exercise, ____________ shares of Common Stock remain subject to the Option, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby represent that it is my intention to acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Section 2(11) of the Securities Act of 1933) the shares you acquire through this Option exercise, the Company or transfer agent may require an opinion of counsel that such resale or distribution would not violate the Securities Act of 1933 prior to your exercise of such Option. Date: , . Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having been exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and treat them as if they are shares acquired by the option exercise. In addition, I will receive additional shares equal to the difference between the shares I constructively exchange and the total new option shares that I acquire. EXHIBIT B ACKNOWLEDGMENT OF RECEIPT OF SHARES I hereby acknowledge the delivery to me by Charter Financial Corporation (the “Company”) or its affiliate on _____________________________, of stock certificates for ____________________ shares of common stock of the Company purchased by me pursuant to the terms and conditions of the Stock Option Agreement and the Charter Financial Corporation 2013 Equity Incentive Plan, as amended applicable, which shares were transferred to date, me on [ ] for the purchase of [ ] shares of Common Stock of the Company at an exercise price of $[ ] per share. I hereby exercise my option to purchase shares of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation of the Securities Act of 1933 (the “Securities Act”), or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company’s stock record books on ____________________. I have sufficient experience in businessDate: , financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have not been registered under the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)Participant’s signature

Appears in 1 contract

Samples: Equity Incentive Plan (Charter Financial Corp)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2015 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2015 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: _______________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by CB Financial Services, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the CB Financial Services, Inc. 2015 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $_______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any minimum required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Incentive Stock Option Award Agreement (CB Financial Services, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended Plan and Restated 2008 Equity Incentive Plan, as amended to daterelated prospectus. PARTICIPANT Date: By: [ ] Address: EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by First Savings Financial Group, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Non-Qualified Stock Option Agreement (the “Agreement”) and the First Savings Financial Group, Inc. 2021 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ My check in the sum of $_______ and stock of the Company with a fair market value of $______, in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any minimum required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _____________________________________________ Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Non Qualified Stock Option Award Agreement (First Savings Financial Group, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2011 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2011 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: ______________________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: (BY EMPLOYEE) I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by OBA Financial Services, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the OBA Financial Services, Inc. 2011 Equity Incentive Plan (the “Plan”) referred to therein, and notify you of my desire to purchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $_______ per share. Enclosed please find (check one): ___ Cash or personal, certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ My check in the sum of $_______ and stock of the Company with a fair market value of $______, in full/partial payment of the purchase price.* ___ Please sell ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock remain subject to the Option, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby represent that it is my intention to acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Section 2(11) of the Securities Act of 1933) the shares you acquire through this Option exercise, the Company or transfer agent may require an opinion of counsel that such resale or distribution would not violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________________ ______________________________________ Participant’s signature * If I elect to exercise by exxxxxxxxx shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and treat them as if they are shares acquired by the option exercise. In addition, I will receive additional shares equal to the difference between the shares I constructively exchange and the total new option shares that I acquire. EXHIBIT B ACKNOWLEDGMENT OF RECEIPT OF SHARES I hereby acknowledge the delivery to me by OBA Financial Services, Inc. (the “Company”) or its affiliate on _____________________________, of stock certificates for ____________________ shares of common stock of the Company purchased by me pursuant to the terms and conditions of the Stock Option Agreement and the OBA Financial Services, Inc. 2011 Equity Incentive Plan, as amended applicable, which shares were transferred to date, me on [ ] for the purchase of [ ] shares of Common Stock of the Company at an exercise price of $[ ] per share. I hereby exercise my option to purchase shares of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation of the Securities Act of 1933 (the “Securities Act”), or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company’s stock record books on ____________________. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have not been registered under the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)Date: ____________________ ______________________________________ Participant’s signature

Appears in 1 contract

Samples: Equity Incentive Plan (OBA Financial Services, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2021 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2021 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals Inc. by Chemung Financial Corporation (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Chemung Financial Corporation 2021 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $_______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Incentive Stock Option Award Agreement (Chemung Financial Corp)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended Plan and Restated 2008 Equity Incentive Plan, as amended related prospectus have been provided or made available to datethe Participant. ​ ​ ​ PARTICIPANT Date: By: [ ] Address: ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Eureka Homestead Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Eureka Homestead Bancorp, Inc. 2020 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $______ per share. ​ I wish to pay the exercise price by (check one or more): ​ ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a Fair Market Value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, whereby I direct the Company to withhold a sufficient number of shares to satisfy the exercise price obtained on exercise in payment of the exercise price of the Option (and, if applicable, any tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___investment ___resale or distribution ​ Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act1933 prior to your exercise of such Option. Date: ____________, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)_____._________________________________________ Participant’s signature ​ ​ ​ ​

Appears in 1 contract

Samples: Non Qualified Stock Option Agreement (Eureka Homestead Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the PB Bankshares, Inc. 2022 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 PB Bankshares, Inc. 2022 Equity Incentive Plan, as amended to datePlan and related prospectus. PARTICIPANT Date_____________________________________ Name: By: [ ] Address: ________________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis PharmaceuticalsI, Inc. Xxx Xxxxxxx Xxxxxx______________________________, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by PB Bankshares, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Non-Qualified Stock Option Agreement (the “Agreement”) and the PB Bankshares, Inc. 2022 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ My check in the sum of $_______ and stock of the Company with a fair market value of $______, in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any minimum required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 1933, as amended (the "Securities Act”)") the shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act1933 prior to your exercise of such Option. Date: _______________, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act20___. Very truly yours, (Signature)_________________________________________ Participant’s signature

Appears in 1 contract

Samples: Non Qualified Stock Option Award Agreement (PB Bankshares, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2017 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2017 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by WCF Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the WCF Bancorp, Inc. 2017 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Non Qualified Stock Option Award Agreement (WCF Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2013 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2013 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: _____________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: (BY EMPLOYEE) I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Madison County Financial, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Madison County Financial, Inc. 2013 Equity Incentive Plan (the “Plan”) referred to therein, and notify you of my desire to purchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $_____________ per share. I wish to pay the purchase price by (check one or more): [Any payment to be delivered must accompany this Notice of Exercise of Option] ___ Cash or personal, certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A “net settlement” of the Option whereby I direct the Company to withhold a sufficient number of shares to satisfy the purchase price. ___ A check (personal, certified or cashier’s) in the sum of $_______ and stock of the Company with a fair market value of $______, in full payment of the purchase price.* ___ Please sell ______ shares from my Option shares through a broker in full/partial payment of the purchase price. If my broker requires additional forms in order to consummate this “broker cashless exercise,” I have included them with this election. I understand that after this exercise, ____________ shares of Common Stock remain subject to the Option, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby represent that it is my intention to acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Section 2(11) of the Securities Act of 1933) the shares you acquire through this Option exercise, the Company or transfer agent may require an opinion of counsel that such resale or distribution would not violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having been exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and treat them as if they are shares acquired by the option exercise. In addition, I will receive additional shares equal to the difference between the shares I constructively exchange and the total new option shares that I acquire. EXHIBIT B ACKNOWLEDGMENT OF RECEIPT OF SHARES I hereby acknowledge the delivery to me by Madison County Financial, Inc. (the “Company”) or its affiliate on _____________________________, of stock certificates for ____________________ shares of common stock of the Company purchased by me pursuant to the terms and conditions of the Stock Option Agreement and the Madison County Financial, Inc. 2013 Equity Incentive Plan, as amended applicable, which shares were transferred to date, me on [ ] for the purchase of [ ] shares of Common Stock of the Company at an exercise price of $[ ] per share. I hereby exercise my option to purchase shares of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation of the Securities Act of 1933 (the “Securities Act”), or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company’s stock record books on ____________________. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have not been registered under the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)Date:_____________ __________________

Appears in 1 contract

Samples: Equity Incentive Plan (Madison County Financial, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2015 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2015 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: ______________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Pilgrim Bancshares, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Pilgrim Bancshares, Inc. 2015 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any minimum required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Non Qualified Stock Option Award Agreement (Pilgrim Bancshares, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2017 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2017 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by PB Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the PB Bancorp, Inc. 2017 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $_______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Incentive Stock Option Award Agreement (PB Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The As of the date of grant of this Option set forth above, the undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2019 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2019 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: EXHIBIT A NOTICE OF EXERCISE OF NON-QUALIFIED STOCK OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals Inc. by MAINSTREET BANCSHARES, INC. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the MAINSTREET BANCSHARES, INC. 2019 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for an aggregate purchase price of $______ per share. I elect to pay the exercise price by: — Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. — Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* — A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any required tax withholding). — Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock remain subject to the Option, subject to all terms and provisions set forth in the Agreement and the Plan. ____________, 20___. _________________________________________ Date Participant’s signature * If I elect to exercise an Option by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company at an exercise price with a statement attesting to the number of $[ ] per shareshares owned that will be treated as having been exchanged. I hereby exercise my option to purchase will keep the shares of Common Stock (the “Shares”), for which that I have enclosed [insert method of payment] in the amount of . Please register my stock certificate already own and treat them as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation of the Securities Act of 1933 (the “Securities Act”), or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have not been registered under the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the total new option shares that I acquire. BY THE COMPANY Date Received: ____________________ Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)Representative: __________________

Appears in 1 contract

Samples: Non Qualified Stock Option Award Agreement (MainStreet Bancshares, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2019 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2019 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Severn Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Severn Bancorp, Inc. 2019 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act1933 prior to your exercise of such Option. Date: ____________, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act_____. Very truly yours, (Signature)_________________________________________ Participant’s signature

Appears in 1 contract

Samples: Equity Incentive Plan (Severn Bancorp Inc)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2016 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2016 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: _______________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Ben Franklin Financial, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Ben Franklin Financial, Inc. 2016 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any minimum required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Non Qualified Stock Option Award Agreement (Ben Franklin Financial, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2016 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2016 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: _______________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by First Savings Financial Group, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the First Savings Financial Group, Inc. 2016 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any minimum required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation of the Securities Act of 1933 (the “Securities Act”), or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have not been registered under the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation following purpose: ___ investment ___ resale or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)distribution

Appears in 1 contract

Samples: Non Qualified Stock Option Award Agreement (First Savings Financial Group Inc)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2016 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2016 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: _________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals Inc. by Kearny Financial Corp. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Kearny Financial Corp. 2016 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $15.35 per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: 2016 Equity Incentive Plan (Kearny Financial Corp.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2015 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2015 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: (BY EMPLOYEE) I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Waterstone Financial, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Waterstone Financial, Inc. 2015 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $_______ per share. I elect to pay the exercise price by (check one): ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any minimum required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Equity Incentive Plan (Waterstone Financial, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2011 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2011 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: ______________________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: (BY OUTSIDE DIRECTOR) I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by OBA Financial Services, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the OBA Financial Services, Inc. 2011 Equity Incentive Plan (the “Plan”) referred to therein, and notify you of my desire to purchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $_____________ per share. Enclosed please find (check one): ___ Cash or personal, certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ My check in the sum of $_______ and stock of the Company with a fair market value of $______, in full/partial payment of the purchase price.* ___ Please sell ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock remain subject to the Option, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby represent that it is my intention to acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Section 2(11) of the Securities Act of 1933) the shares you acquire through this Option exercise, the Company or transfer agent may require an opinion of counsel that such resale or distribution would not violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________________ ______________________________________ Participant’s signature * If I elect to exercise by exxxxxxxxx shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and treat them as if they are shares acquired by the option exercise. In addition, I will receive additional shares equal to the difference between the shares I constructively exchange and the total new option shares that I acquire. EXHIBIT B ACKNOWLEDGMENT OF RECEIPT OF SHARES I hereby acknowledge the delivery to me by OBA Financial Services, Inc. (the “Company”) or its affiliate on _____________________________, of stock certificates for ____________________ shares of common stock of the Company purchased by me pursuant to the terms and conditions of the Stock Option Agreement and the OBA Financial Services, Inc. 2011 Equity Incentive Plan, as amended applicable, which shares were transferred to date, me on [ ] for the purchase of [ ] shares of Common Stock of the Company at an exercise price of $[ ] per share. I hereby exercise my option to purchase shares of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation of the Securities Act of 1933 (the “Securities Act”), or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company’s stock record books on ____________________. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have not been registered under the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)Date: ____________________ ______________________________________ Participant’s signature

Appears in 1 contract

Samples: Equity Incentive Plan (OBA Financial Services, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2010 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2010 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: (BY EMPLOYEES) I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Territorial Bancorp Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Territorial Bancorp Inc. 2010 Equity Incentive Plan (the “Plan”) referred to therein, and notify you of my desire to purchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $_________ per share. I am exercising ___________ Incentive Stock Options ___________ Non-qualified Stock Options Enclosed please find (check one or more, as applicable): ¨ Cash, personal, certified or cashier’s check in the sum of $ , in full/partial payment of the purchase price. ¨ Stock of the Company with a fair market value of $______ in full/partial payment of the purchase price.* ¨ My check in the sum of $_______ and stock of the Company with a fair market value of $ , in full/partial payment of the purchase price.* ¨ Please sell ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock remain subject to the Option, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby represent that it is my intention to acquire these shares for the following purpose: ¨ investment ¨ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Section 2(11) of the Securities Act of 1933) the shares you acquire through this Option exercise, the Company or transfer agent may require an opinion of counsel that such resale or distribution would not violate the Securities Act of 1933 prior to your exercise of such Option. Date: _________________, ________. Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and treat them as if they are shares acquired by the option exercise. In addition, I will receive additional shares equal to the difference between the shares I constructively exchange and the total new option shares that I acquire. EXHIBIT B ACKNOWLEDGMENT OF RECEIPT OF SHARES I hereby acknowledge the delivery to me by Territorial Bancorp Inc. (the “Company”) or its affiliate on _____________________________, of stock certificates for ____________________ shares of common stock of the Company purchased by me pursuant to the terms and conditions of the Stock Option Agreement and the Territorial Bancorp Inc. 2010 Equity Incentive Plan, as amended applicable, which shares were transferred to dateme on the Company’s stock record books on ____________________. Date: Participant’s signature EXHIBIT TO FORM OF STOCK OPTION AGREEMENT On August 19, on [ ] 2010, the Compensation Committee awarded the following stock options to our named executive officers: Xx. Xxxxxxxx was granted an option to acquire 205,979 shares; Xx. Xxxxxxxx was granted an option to acquire 19,524 shares; Xx. Xxxxxx was granted an option to acquire 153,930 shares; Xx. Xxxxxxxxx was granted an option to acquire 146,430 shares; and Xx. Xxx was granted an option to acquire 19,524 shares. The exercise price for the purchase of [ ] shares of Common Stock all of the Company at an exercise options is $17.36, which was the closing price of $[ ] per shareTerritorial Bancorp Inc. stock on the grant date. I hereby exercise my option to purchase shares of Common Stock (the “Shares”)All options expire on August 19, for which I have enclosed [insert method of payment] in the amount of 2020. Please register my stock certificate The awards vest as follows: Name(s): Address: Tax I.D. #: I representDate Vested Portion of Award August 19, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only2010 0/6 August 19, and not with a view to2011 1/6 August 19, or for sale in connection with2012 2/6 August 19, any distribution of the Shares in violation of the Securities Act of 1933 (the “Securities Act”)2013 3/6 August 19, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business2014 4/6 August 19, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have not been registered under the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)2015 5/6

Appears in 1 contract

Samples: Equity Incentive Plan (Territorial Bancorp Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2017 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 's 2017 Equity Incentive Plan, as amended to date. PARTICIPANT ___________________________________________ Date: By: [ ] Address: ___________________________ Name (print) _________________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the "Option") granted to me under the Catabasis Pharmaceuticals by Bancorp 34, Inc. (the "Company") Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the "Agreement") and the Bancorp 34, Inc. 2017 Equity Incentive Plan (the "Plan") referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company ("Common Stock") for a purchase price of $_______ per share. I elect to pay the exercise price by: ___ Personal, on [ ] for certified or cashier's check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act1933 prior to your exercise of such Option. Date: ____________, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act_____. Very truly yours, (Signature)_________________________________________ Participant's signature

Appears in 1 contract

Samples: Incentive Stock Option Award Agreement (Bancorp 34, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2013 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2013 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: (BY EMPLOYEE) I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals Inc. by Charter Financial Corporation (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Charter Financial Corporation 2013 Equity Incentive Plan (the “Plan”) referred to therein, and notify you of my desire to purchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $_______ per share. I wish to pay the purchase price by (check one or more, as applicable): [Any payment to be delivered must accompany this Notice of Exercise of Option] ___ Cash or personal, certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A “net settlement” of the Option whereby I direct the Company to withhold a sufficient number of shares to satisfy the purchase price. ___ A check (personal, certified or cashier’s) in the sum of $_______ and stock of the Company with a fair market value of $______, in full payment of the purchase price.* ___ Please sell ______ shares from my Option shares through my broker in full/partial payment of the purchase price. If my broker requires additional forms in order to consummate this “broker cashless exercise,” I have included them with this election. I understand that after this exercise, ____________ shares of Common Stock remain subject to the Option, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby represent that it is my intention to acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Section 2(11) of the Securities Act of 1933) the shares you acquire through this Option exercise, the Company or transfer agent may require an opinion of counsel that such resale or distribution would not violate the Securities Act of 1933 prior to your exercise of such Option. Date: , . Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having been exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and treat them as if they are shares acquired by the option exercise. In addition, I will receive additional shares equal to the difference between the shares I constructively exchange and the total new option shares that I acquire. EXHIBIT B ACKNOWLEDGMENT OF RECEIPT OF SHARES I hereby acknowledge the delivery to me by Charter Financial Corporation (the “Company”) or its affiliate on _____________________________, of stock certificates for ____________________ shares of common stock of the Company purchased by me pursuant to the terms and conditions of the Stock Option Agreement and the Charter Financial Corporation 2013 Equity Incentive Plan, as amended applicable, which shares were transferred to date, me on [ ] for the purchase of [ ] shares of Common Stock of the Company at an exercise price of $[ ] per share. I hereby exercise my option to purchase shares of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation of the Securities Act of 1933 (the “Securities Act”), or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company’s stock record books on ____________________. I have sufficient experience in businessDate: , financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have not been registered under the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)Participant’s signature

Appears in 1 contract

Samples: Equity Incentive Plan (Charter Financial Corp)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2015 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2015 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: ____________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Melrose Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Melrose Bancorp, Inc. 2015 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any minimum required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Non Qualified Stock Option Award Agreement (Melrose Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2010 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2010 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: (BY OUTSIDE DIRECTORS) I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Territorial Bancorp Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Territorial Bancorp Inc. 2010 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase shares of common stock of the Company (“Common Stock”) for a purchase price of $ per share. Enclosed please find (check one): ¨ Cash, on [ ] for personal, certified or cashier’s check in the sum of $ , in full/partial payment of the purchase price. ¨ Stock of [ ] the Company with a fair market value of $ in full/partial payment of the purchase price.* ¨ My check in the sum of $ and stock of the Company with a fair market value of $ , in full/partial payment of the purchase price.* ¨ Please sell shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ¨ investment ¨ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed 1933 prior to your exercise of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)such Option.

Appears in 1 contract

Samples: Equity Incentive Plan (Territorial Bancorp Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the Cullman Bancorp, Inc. 2023 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 Cullman Bancorp, Inc. 2023 Equity Incentive Plan, as amended to datePlan and related prospectus. PARTICIPANT Date: By: [ ] Address: ________________________________ Name:___________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis PharmaceuticalsI, Inc. Xxx Xxxxxxx Xxxxxx______________________________, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Cullman Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Non-Qualified Stock Option Agreement (the “Agreement”) and the Cullman Bancorp, Inc. 2023 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ My check in the sum of $_______ and stock of the Company with a fair market value of $______, in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any minimum required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 1933, as amended (the "Securities Act”)") the shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: _______________, 20___. _________________________________________ Participant’s signature * If I elect to exercise by xxxxxxxxxx shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Non Qualified Stock Option Award Agreement (Cullman Bancorp, Inc. /MD/)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2015 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2015 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: (BY OUTSIDE DIRECTORS) I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Meridian Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Meridian Bancorp, Inc. 2015 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase shares of common stock of the Company (“Common Stock”) for a purchase price of $ per share. Enclosed please find (check one): Cash, on [ ] for personal, certified or cashier’s check in the sum of $ , in full/partial payment of the purchase price. Stock of [ ] the Company with a fair market value of $ in full/partial payment of the purchase price.* My check in the sum of $ and stock of the Company with a fair market value of $ , in full/partial payment of the purchase price.* Please sell shares from my Option shares through a broker in full/partial payment of the purchase price. By a net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and if applicable, any minimum required tax withholding). I understand that after this exercise, shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: investment resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: , . Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Equity Incentive Plan (Meridian Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2015 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2015 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: ________________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Pilgrim Bancshares, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Pilgrim Bancshares, Inc. 2015 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $_______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any minimum required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Incentive Stock Option Award Agreement (Pilgrim Bancshares, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2019 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2019 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: ___________________________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by SSB Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the SSB Bancorp, Inc. 2019 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act1933 prior to your exercise of such Option. Date: ____________, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act_____. Very truly yours, (Signature)_________________________________________ Participant’s signature

Appears in 1 contract

Samples: Non Qualified Stock (SSB Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2017 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2017 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by WCF Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the WCF Bancorp, Inc. 2017 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $_______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Incentive Stock Option Award Agreement (WCF Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The As of the date of grant of this Option set forth above, the undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2019 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2019 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: EXHIBIT A NOTICE OF EXERCISE OF INCENTIVE STOCK OPTION EXERCISE Date: Catabasis Pharmaceuticals(ISO) I hereby exercise, Inc. Xxx Xxxxxxx Xxxxxxall or part of, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir the incentive stock option (the “Option” or Madam: I am the holder of an Incentive Stock Option “ISO”) granted to me under the Catabasis Pharmaceuticals by CBM Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the CBM Bancorp, Inc. 2019 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $________, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $_______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any required tax withholding). ___ Selling _______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock remain subject to the Option, subject to all terms and provisions set forth in the Agreement and the Plan. ____________, 20___. _________________________________________ Date of Exercise Participant’s signature * If I elect to exercise an Option by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company at an exercise price with a statement attesting to the number of $[ ] per shareshares owned that will be treated as having been exchanged. I hereby exercise my will keep the shares that I already own and treat them as if they are shares acquired by the option exercise. In addition, I will receive additional shares equal to purchase the difference between the shares of Common Stock (I constructively exchange and the “Shares”), for which total new option shares that I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation of the Securities Act of 1933 (the “Securities Act”), or any rule or regulation under the Securities Actacquire. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand certify that either (i) I have held the Shares have not been registered under shares I am tendering for at least one year after acquiring such shares through the Securities Act and are “restricted securities” within the meaning exercise of Rule 144 under the Securities Actan ISO, or (ii) I have not obtained such shares through the Shares cannot be soldexercise of an ISO. Further, transferred or otherwise disposed I acknowledges that if I am exercising ISO options, failure to retain such shares for a minimum of unless they are subsequently registered under one year from the Securities Act or an exemption from registration is then available; (iii) date of exercise will result in any event, the exemption from registration under Rule 144 will not be available for a disqualified disposition and immediate taxation at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Actordinary income tax rates. Very truly yours, (Signature)BY THE COMPANY

Appears in 1 contract

Samples: Form of Incentive Stock Option Award Agreement (CBM Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the Company’s 2016 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2016 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: _______________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by First Savings Financial Group, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the First Savings Financial Group, Inc. 2016 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $_______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any minimum required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation of the Securities Act of 1933 (the “Securities Act”), or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have not been registered under the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation following purpose: ___ investment ___ resale or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)distribution

Appears in 1 contract

Samples: Incentive Stock Option Award Agreement (First Savings Financial Group Inc)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2015 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2015 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: (BY EMPLOYEES) I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Meridian Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Meridian Bancorp, Inc. 2015 Equity Incentive Plan (the “Plan”) referred to therein, and notify you of my desire to purchase shares of common stock of the Company (“Common Stock”) for a purchase price of $ per share. I am exercising Incentive Stock Options Non-qualified Stock Options Enclosed please find (check one or more, as amended to dateapplicable): Cash, on [ ] for personal, certified or cashier’s check in the sum of $ , in full/partial payment of the purchase price. Stock of [ ] the Company with a fair market value of $ in full/partial payment of the purchase price.* My check in the sum of $ and stock of the Company with a fair market value of $ , in full/partial payment of the purchase price.* Please sell shares from my Option shares through a broker in full/partial payment of the purchase price. By a net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and if applicable, any minimum required tax withholding). I understand that after this exercise, shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: investment resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: , . Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Equity Incentive Plan (Meridian Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the Texas Community Bancshares, Inc. 2022 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 Texas Community Bancshares, Inc. 2022 Equity Incentive Plan, as amended to datePlan and related prospectus. PARTICIPANT Date____________________________________ Name: By: [ ] Address: _______________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis PharmaceuticalsI, Inc. Xxx Xxxxxxx Xxxxxx______________________________, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Texas Community Bancshares, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Incentive Stock Option Agreement (the “Agreement”) and the Texas Community Bancshares, Inc. 2022 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $________ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ My check in the sum of $_______ and stock of the Company with a fair market value of $______, in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any minimum required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 1933, as amended (the "Securities Act"), or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of shares you acquire through this Option exercise, the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act prior to your exercise of such Option. Date: _______________, 20___ _________________________________________ Participant’s signature * If I elect to exercise by xxxxxxxxxx shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Incentive Stock Option Award Agreement (Texas Community Bancshares, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2016 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2016 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: _______________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Ben Franklin Financial, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Ben Franklin Financial, Inc. 2016 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $_______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any minimum required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Incentive Stock Option Award Agreement (Ben Franklin Financial, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2011 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2011 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: Participant EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: (BY EMPLOYEES) I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Northwest Bancshares, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Northwest Bancshares, Inc. 2011 Equity Incentive Plan (the “Plan”) referred to therein, and notify you of my desire to purchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $_________ per share. I am exercising _________ Incentive Stock Options _________ Non-qualified Stock Options Enclosed please find (check one or more, as applicable): ___ Cash, personal, certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ My check in the sum of $_______ and stock of the Company with a fair market value of $______, in full/partial payment of the purchase price.* ___ Please sell ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock remain subject to the Option, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby represent that it is my intention to acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Section 2(11) of the Securities Act of 1933) the shares you acquire through this Option exercise, the Company or transfer agent may require an opinion of counsel that such resale or distribution would not violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. Participant’s signature * If I elect to exercise by xxxxxxxxxx shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and treat them as if they are shares acquired by the option exercise. In addition, I will receive additional shares equal to the difference between the shares I constructively exchange and the total new option shares that I acquire. EXHIBIT B ACKNOWLEDGMENT OF RECEIPT OF SHARES I hereby acknowledge the delivery to me by Northwest Bancshares, Inc. (the “Company”) or its affiliate on _____________________________, of stock certificates for ____________________ shares of common stock of the Company purchased by me pursuant to the terms and conditions of the Stock Option Agreement and the Northwest Bancshares, Inc. 2011 Equity Incentive Plan, as amended applicable, which shares were transferred to date, me on [ ] for the purchase of [ ] shares of Common Stock of the Company at an exercise price of $[ ] per share. I hereby exercise my option to purchase shares of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation of the Securities Act of 1933 (the “Securities Act”), or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company’s stock record books on ____________________. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have not been registered under the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)Date: Participant’s signature

Appears in 1 contract

Samples: 2011 Equity Incentive Plan (Northwest Bancshares, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended Plan and Restated 2008 Equity Incentive Plan, as amended to daterelated prospectus. PARTICIPANT Date: By: [ ] Address: EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by First Savings Financial Group, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Incentive Stock Option Agreement (the “Agreement”) and the First Savings Financial Group, Inc. 2021 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ My check in the sum of $_______ and stock of the Company with a fair market value of $______, in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any minimum required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Incentive Stock Option Award Agreement (First Savings Financial Group, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2020 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2020 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: Name (print): EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by The Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and The Bancorp, Inc. 2020 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $_______ per share. Enclosed please find (check one): ___ Cash, on [ ] for personal, certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ My check in the sum of $_______ and stock of the Company with a fair market value of $______, in full/partial payment of the purchase price.* ___ Please sell ______ shares from my Option shares through a broker in full/partial payment of the purchase price. ___ By a net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and if applicable, any minimum required tax withholding). I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Non Qualified Stock Option Award Agreement (Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2021 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2021 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals Inc. by Chemung Financial Corporation (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Chemung Financial Corporation 2021 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Non Qualified Stock Option Award Agreement (Chemung Financial Corp)

PARTICIPANT’S ACCEPTANCE. The undersigned I, , hereby accepts accept the foregoing option award agreement and agrees agree to the terms and conditions thereof. The undersigned Furthermore, I hereby acknowledges receipt of acknowledge having received and read a copy of the Company’s Amended 2010 Stock Incentive Plan and Restated 2008 Equity Incentive Plan, as amended agree to datecomply with it and all applicable laws and regulations. PARTICIPANT DatePARTICIPANT: By: [ ] Address: Exhibit A NOTICE OF STOCK OPTION EXERCISE Date: Catabasis Pharmaceuticals1 Zipcar, Inc. Xxx Xxxxxxx 00 Xxxxx Xxxxxx, Suite B14202 CambridgeXxxxxx Xxxxx Xxxxxxxxx, MA 02139 XX 00000 Attention: Treasurer Dear Sir or Madam: I am the holder of an Incentive 2 Stock Option granted to me under the Catabasis Pharmaceuticals Zipcar, Inc. (the “Company”) Amended and Restated 2008 Equity 2010 Stock Incentive Plan, as amended to date, Plan on [ ] 3 for the purchase of [ ] 4 shares of Common Stock of the Company at an exercise a purchase price of $[ ] $ 5 per share. I hereby exercise my option to purchase 6 shares of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] 7 in the amount of 8. Please register my stock certificate as follows: Name(s): 9 Address: Tax I.D. #: 10 1 Enter the date of exercise. 2 Enter either “an Incentive” or “a Nonstatutory”. 3 Enter the date of grant. 4 Enter the total number of shares of Common Stock for which the option was granted. 5 Enter the option exercise price per share of Common Stock. 6 Enter the number of shares of Common Stock to be purchased upon exercise of all or part of the option. 7 Enter “cash”, “personal check” or if permitted by the option or Plan, “stock certificates No. XXXX and XXXX”. 8 Enter the dollar amount (price per share of Common Stock times the number of shares of Common Stock to be purchased), or the number of shares tendered. Fair market value of shares tendered, together with cash or check, must cover the purchase price of the shares issued upon exercise. 9 Enter name(s) to appear on stock certificate: (a) Your name only; (b) Your name and other name (i.e., Xxxx Xxx and Xxxx Xxx, Joint Tenants With Right of Survivorship); or (c) In the case of a Nonstatutory option only, a Child’s name, with you as custodian (i.e., Xxxx Xxx, Custodian for Xxxxx Xxx). Note: There may be income and/or gift tax consequences of registering shares in a Child’s name. 10 Social Security Number of Holder(s). I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation of the Securities Act of 1933 (the “Securities Act”), or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have not been registered under the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature):

Appears in 1 contract

Samples: Incentive Stock Option Agreement (Zipcar Inc)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2019 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2019 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: __________________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by SSB Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the SSB Bancorp, Inc. 2019 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act1933 prior to your exercise of such Option. Date: ____________, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act_____. Very truly yours, (Signature)_________________________________________ Participant’s signature

Appears in 1 contract

Samples: 2019 Equity Incentive Plan (SSB Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended Plan and Restated 2008 Equity Incentive Plan, as amended to daterelated prospectus. PARTICIPANT Date: By: [ ] Address: ____________________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Dime Community Bancshares, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Dime Community Bancshares, Inc. 2021 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify the Company of my desire to date, on [ ] purchase __________________ shares of common stock of the Company for a purchase price of $_____________ per share. I wish to pay the purchase price by (check one or more): [Any payment to be delivered must accompany this Notice of [ Exercise of Option] shares ___ Personal, certified or cashier’s check in the sum of Common $_______ in full/partial payment of the purchase price. ___ Stock of the Company at an exercise price with a fair market value of $______ in full/partial payment of the purchase price.* ___ A “net settlement” of the Option whereby I direct the Company to withhold a sufficient number of shares to satisfy the purchase price. Withhold a sufficient number of shares to pay minimum required taxes [ ] per shareCalculate minimum required withholding and I will submit payment. ___ A check (personal, certified or cashier’s) in the sum of $_______ and Stock of the Company with a fair market value of $______, in full payment of the purchase price.* ___ Please sell ______ shares from my Option shares through a broker in full/partial payment of the purchase price. If my broker requires additional forms in order to consummate this “broker cashless exercise,” I have included them with this election. I understand that after this exercise, ____________ shares of Stock remain subject to the Option, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by xxxxxxxxxx shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having been exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Equity Incentive Plan (Dime Community Bancshares, Inc. /NY/)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2017 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 's 2017 Equity Incentive Plan, as amended to date. PARTICIPANT ___________________________________________ Date: By: [ ] Address: ___________________________ Name (print) _________________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the "Option") granted to me under the Catabasis Pharmaceuticals by Bancorp 34, Inc. (the "Company") Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the "Agreement") and the Bancorp 34, Inc. 2017 Equity Incentive Plan (the "Plan") referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company ("Common Stock") for a purchase price of $______ per share. I elect to pay the exercise price by: ___ Personal, on [ ] for certified or cashier's check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act1933 prior to your exercise of such Option. Date: ____________, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act_____. Very truly yours, (Signature)_________________________________________ Participant's signature

Appears in 1 contract

Samples: Non Qualified Stock Option Award Agreement (Bancorp 34, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2016 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2016 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: _________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals Inc. by Kearny Financial Corp. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Kearny Financial Corp. 2016 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: 2016 Equity Incentive Plan (Kearny Financial Corp.)

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PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2014 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2014 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: _________________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: (BY OUTSIDE DIRECTOR) I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Sunnyside Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Sunnyside Bancorp, Inc. 2014 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $______ per share. I elect to pay the exercise price by (check one): ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any minimum required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act1933 prior to your exercise of such Option. Date: ____________, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act_____. Very truly yours, (Signature)_________________________________________ Participant’s signature

Appears in 1 contract

Samples: 2014 Equity Incentive Plan (Sunnyside Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2020 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2020 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: _________________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Pioneer Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Pioneer Bancorp, Inc. 2020 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act1933 prior to your exercise of such Option. Date: ____________, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act_____. Very truly yours, (Signature)_________________________________________ Participant’s signature

Appears in 1 contract

Samples: Non Qualified Stock (Pioneer Bancorp, Inc./Md)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2014 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2014 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: Schedule The above form of Stock Option Agreement was signed by Xxxx X. Xxxxxxxxx, Chairman and Chief Executive Officer (225,000 shares), and Xxxxxx X. Xxxxx, President and Chief Operating Officer (135,000 shares). EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: (BY EMPLOYEE) I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Northfield Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Northfield Bancorp, Inc. 2014 Equity Incentive Plan (the “Plan”) referred to therein, and notify you of my desire to purchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $_______ per share. I wish to pay the purchase price by (check one or more, as amended applicable): [Any payment to datebe delivered must accompany this Notice of Exercise of Option] ___ Cash or personal, on certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A “net settlement” of the Option whereby I direct the Company to withhold a sufficient number of shares to satisfy the purchase price. [ ] for Withhold a sufficient number of shares to pay minimum required taxes [ ] Calculate minimum required withholding and I will submit payment. ___ A check (personal, certified or cashier’s) in the sum of $_______ and stock of the Company with a fair market value of $______, in full payment of the purchase price.* ___ Please sell ______ shares from my Option shares through my broker in full/partial payment of [ ] the purchase price. If my broker requires additional forms in order to consummate this “broker cashless exercise,” I have included them with this election. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, the Company or any rule transfer agent may require an opinion of counsel that such resale or regulation under distribution would not violate the Securities ActAct of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having been exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I have had such opportunity will keep the shares that I already own and treat them as if they are shares acquired by the option exercise. In addition, I have deemed adequate will receive additional shares equal to obtain the difference between the shares I constructively exchange and the total new option shares that I acquire. EXHIBIT B EXAMPLE: Assume the employee is granted 500,000 Option Awards on July 1, 2014. The Option Award vests at the rate of 20% per year (i.e., 100,000 shares per year) commencing one year from representatives the date of grant. Also assume each director is granted 100,000 Option Awards on July 1, 2014 and that each director’s awards vest at the rate of 20% per year (i.e., 20,000 shares per year) commencing one year from the date of grant. Further assume that the employee resigns as an employee, effective December 31, 2016, but continues in the service of the Company such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase a member of the Shares and to make an informed investment decision with respect to such purchaseBoard. I can afford a complete loss At the time of the value employee’s resignation, the employee would have vested in an aggregate of 200,000 Option Awards (on July 1, 2015 and July 1, 2016). The employee’s resignation occurs six months into the third vesting year. Accordingly, on July 1, 2017, the former employee would vest in 60,000 Option Awards, calculated as follows: 100,000 Option Awards (employee grant) x 6/12 (July – December) = 50,000 20,000 Option Awards (director grant) x 6/12 (January through June) = 10,000 Further, the former employee would forfeit 80,000 Option Awards from each of the Shares installments vesting July 1, 2018 and am able to bear July 1, 2019. The effect of this is that the economic risk former employee would vest in a number of holding such Shares for Stock Options during the two years in which he performed no services as an indefinite period. I understand that (i) the Shares have not been registered under the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available employee equal to the public, and same number of Stock Options in which the other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)non-employee directors vest for such years.

Appears in 1 contract

Samples: 2014 Equity Incentive Plan (Northfield Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2014 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2014 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: ___________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: (BY EMPLOYEE) I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Georgetown Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Georgetown Bancorp, Inc. 2014 Equity Incentive Plan (the “Plan”) referred to therein, and notify you of my desire to purchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $_______ per share. I elect to pay the exercise price by (check one): ___ Cash or personal, certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any minimum required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock remain subject to the Option, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby represent that it is my intention to acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Section 2(11) of the Securities Act of 1933) the shares you acquire through this Option exercise, the Company or transfer agent may require an opinion of counsel that such resale or distribution would not violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and treat them as if they are shares acquired by the option exercise. In addition, I will receive additional shares equal to the difference between the shares I constructively exchange and the total new option shares that I acquire. EXHIBIT B ACKNOWLEDGMENT OF RECEIPT OF SHARES I hereby acknowledge the delivery to me by Georgetown Bancorp, Inc. (the “Company”) or its affiliate on _____________________________, of stock certificates for ____________________ shares of common stock of the Company purchased by me pursuant to the terms and conditions of the Stock Option Agreement and the Georgetown Bancorp, Inc. 2014 Equity Incentive Plan, as amended applicable, which shares were transferred to date, me on [ ] for the purchase of [ ] shares of Common Stock of the Company at an exercise price of $[ ] per share. I hereby exercise my option to purchase shares of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation of the Securities Act of 1933 (the “Securities Act”), or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company’s stock record books on ____________________. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have not been registered under the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)Date: ____________________ _______________________ Participant’s signature

Appears in 1 contract

Samples: 2014 Equity Incentive Plan (Georgetown Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2015 Stock Option Plan. The undersigned hereby acknowledges receipt of a copy of the CompanyBank’s Amended and Restated 2008 Equity Incentive 2015 Stock Option Plan, as amended to date. PARTICIPANT Date: By: [ [Name] Address: EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: (BY OUTSIDE DIRECTORS) I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals Inc. by 1st Manatee Bank (the “CompanyBank”), subject to all the terms and provisions set forth in the Stock Option Agreement (the “Agreement”) Amended and Restated 2008 Equity Incentive the 1st Manatee Bank 2015 Stock Option Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Bank (“Common Stock”) for a purchase price of $_________ per share. Enclosed please find (check one): ___ Cash, on [ ] for personal, certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Bank with a fair market value of $______ in full/partial payment of the purchase price.* ___ My check in the sum of $_______ and stock of the Bank with a fair market value of $______, in full/partial payment of the purchase price.* I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (the “Securities Act”), or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i1933) the Shares have shares you acquire through this Option exercise, the Bank or transfer agent may require an opinion of counsel that such resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Bank with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: 2015 Stock Option Plan (National Commerce Corp)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the Bank’s 2015 Stock Option Plan. The undersigned hereby acknowledges receipt of a copy of the CompanyBank’s Amended and Restated 2008 Equity Incentive 2015 Stock Option Plan, as amended to date. PARTICIPANT Date: By: [ [Name] Address: EMPLOYEE EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: (BY EMPLOYEE) I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals Inc. by 1st Manatee Bank (the “CompanyBank”), subject to all the terms and provisions set forth in the Stock Option Agreement (the “Agreement”) Amended and Restated 2008 Equity Incentive the 1st Manatee Bank 2015 Stock Option Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Bank (“Common Stock”) for a purchase price of $_______ per share. Enclosed please find (check one): ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Bank with a fair market value of $______ in full/partial payment of the purchase price.* ___ My check in the sum of $_______ and stock of the Bank with a fair market value of $______, in full/partial payment of the purchase price.* I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (the “Securities Act”), or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i1933) the Shares have shares you acquire through this Option exercise, the Bank or transfer agent may require an opinion of counsel that such resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Bank with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: 2015 Stock Option Plan (National Commerce Corp)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2015 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2015 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: ______________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Melrose Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Melrose Bancorp, Inc. 2015 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $_______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any minimum required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Incentive Stock Option Award Agreement (Melrose Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2020 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2020 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: Name (print): EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: (BY OUTSIDE DIRECTORS) I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by The Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and The Bancorp, Inc. 2020 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $_________ per share. Enclosed please find (check one): ___ Cash, on [ ] for personal, certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ My check in the sum of $_______ and stock of the Company with a fair market value of $______, in full/partial payment of the purchase price.* ___ Please sell ______ shares from my Option shares through a broker in full/partial payment of the purchase price. ___ By a net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and if applicable, any minimum required tax withholding). I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: 2020 Equity Incentive Plan (Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2018 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 's 2018 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: ________________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the "Option") granted to me under the Catabasis Pharmaceuticals by Eagle Financial Bancorp, Inc. (the "Company") Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the "Agreement") and the Eagle Financial Bancorp, Inc. 2018 Equity Incentive Plan (the "Plan") referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company ("Common Stock") for a purchase price of $______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier's check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act1933 prior to your exercise of such Option. Date: ____________, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act_____. Very truly yours, (Signature)_________________________________________ Participant's signature

Appears in 1 contract

Samples: Non Qualified Stock (Eagle Financial Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2013 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2013 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: __________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: (BY OUTSIDE DIRECTOR) I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Xxxxxxxx Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Xxxxxxxx Bancorp, Inc. 2013 Equity Incentive Plan (the “Plan”) referred to therein, and notify you of my desire to purchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $_____________ per share. I wish to pay the purchase price by (check one or more): [Any payment to be delivered must accompany this Notice of Exercise of Option] ___ Cash or personal, certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A “net settlement” of the Option whereby I direct the Company to withhold a sufficient number of shares to satisfy the purchase price. ___ A check (personal, certified or cashier’s) in the sum of $_______ and stock of the Company with a fair market value of $______, in full payment of the purchase price.* ___ Please sell ______ shares from my Option shares through a broker in full/partial payment of the purchase price. If my broker requires additional forms in order to consummate this “broker cashless exercise,” I have included them with this election. I understand that after this exercise, ____________ shares of Common Stock remain subject to the Option, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby represent that it is my intention to acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Section 2(11) of the Securities Act of 1933) the shares you acquire through this Option exercise, the Company or transfer agent may require an opinion of counsel that such resale or distribution would not violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having been exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and treat them as if they are shares acquired by the option exercise. In addition, I will receive additional shares equal to the difference between the shares I constructively exchange and the total new option shares that I acquire. EXHIBIT B ACKNOWLEDGMENT OF RECEIPT OF SHARES I hereby acknowledge the delivery to me by Xxxxxxxx Bancorp, Inc. (the “Company”) or its affiliate on _____________________________, of stock certificates for ____________________ shares of common stock of the Company purchased by me pursuant to the terms and conditions of the Stock Option Agreement and the Xxxxxxxx Bancorp, Inc. 2013 Equity Incentive Plan, as amended applicable, which shares were transferred to date, me on [ ] for the purchase of [ ] shares of Common Stock of the Company at an exercise price of $[ ] per share. I hereby exercise my option to purchase shares of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation of the Securities Act of 1933 (the “Securities Act”), or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company’s stock record books on ____________________. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have not been registered under the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)Date:________________ ___________________________

Appears in 1 contract

Samples: 2013 Equity Incentive Plan (Hamilton Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2019 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2019 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: _________________________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals Inc. by Metropolitan Bank Holding Corp. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Metropolitan Bank Holding Corp. 2019 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: 2019 Equity Incentive Plan (Metropolitan Bank Holding Corp.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the Blue Foundry Bancorp 2022 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 Blue Foundry Bancorp 2022 Equity Incentive Plan, as amended to datePlan and related prospectus. PARTICIPANT Date__________________________ Name: By: [ ] Address: _____________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis PharmaceuticalsI, Inc. Xxx Xxxxxxx Xxxxxx______________________________, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals Inc. by Blue Foundry Bancorp (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Incentive Stock Option Agreement (the “Agreement”) and the Blue Foundry Bancorp 2022 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $________ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ My check in the sum of $_______ and stock of the Company with a fair market value of $______, in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any minimum required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 1933, as amended (the "Securities Act"), or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of shares you acquire through this Option exercise, the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act and are “restricted securities” within the meaning prior to your exercise of Rule 144 under the Securities Actsuch Option. Date: _______________, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)20___ _________________________________________ Participant’s signature

Appears in 1 contract

Samples: Incentive Stock Option Award Agreement (Blue Foundry Bancorp)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2020 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2020 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: __________________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by 1895 Bancorp of Wisconsin, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the 1895 Bancorp of Wisconsin, Inc. 2020 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by xxxxxxxxxx shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Non Qualified Stock Option (1895 Bancorp of Wisconsin, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2019 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2019 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: __________________________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals Inc. by Metropolitan Bank Holding Corp. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Metropolitan Bank Holding Corp. 2019 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Non Qualified Stock (Metropolitan Bank Holding Corp.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2017 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2017 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by PB Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the PB Bancorp, Inc. 2017 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Non Qualified Stock Option Award Agreement (PB Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2017 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2017 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: _________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals Inc. by Cincinnati Bancorp (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Cincinnati Bancorp 2017 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act1933 prior to your exercise of such Option. Date: ____________, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act_____. Very truly yours, (Signature)_________________________________________ Participant’s signature

Appears in 1 contract

Samples: Equity Incentive Plan (Cincinnati Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended Plan and Restated 2008 Equity Incentive Plan, as amended to daterelated prospectus. PARTICIPANT Date: By: [ ] Address: ________________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Pathfinder Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Incentive Stock Option Agreement (the “Agreement”) and the Pathfinder Bancorp, Inc. 2024 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ My check in the sum of $_______ and stock of the Company with a fair market value of $______, in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any minimum required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by xxxxxxxxxx shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Incentive Stock Option Award Agreement (Pathfinder Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the VWF Bancorp, Inc. 2023 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 VWF Bancorp, Inc. 2023 Equity Incentive Plan, as amended to datePlan and related prospectus. ​ ​ ​ ​ PARTICIPANT Date​ ​ ​ ​ ​ ​ ​ Name: By: [ ] Address: ​ ​ ​ ​ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals​ I, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by VWF Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Incentive Stock Option Agreement (the “Agreement”) and the VWF Bancorp, Inc. 2023 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase shares of common stock of the Company (“Common Stock”) for a purchase price of $ per share. ​ I elect to pay the exercise price by: ​ ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $ , in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $ in full/partial payment of the purchase price.* ___ My check in the sum of $ and stock of the Company with a fair market value of $ , in full/partial payment of the purchase price.* ​ ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any minimum required tax withholding). ___ Selling shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___investment ___resale or distribution ​ Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 1933, as amended (the "Securities Act"), or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of shares you acquire through this Option exercise, the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act prior to your exercise of such Option. Date: , 20 ​ ​ Participant’s signature ​ *If I elect to exercise by xxxxxxxxxx shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Incentive Stock Option Award Agreement (VWF Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2021 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2021 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: ___________________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals Inc. by Bogota Financial Corp. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Bogota Financial Corp. 2021 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any tax withholding). ___ Selling ______ shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act1933 prior to your exercise of such Option. Date: ____________, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act_____. Very truly yours, (Signature)_________________________________________ Participant’s signature

Appears in 1 contract

Samples: Non Qualified (Bogota Financial Corp.)

PARTICIPANT’S ACCEPTANCE. The undersigned I, , hereby accepts accept the foregoing option award agreement and agrees agree to the terms and conditions thereof. The undersigned Furthermore, I hereby acknowledges receipt of acknowledge having received and read a copy of the Company’s Amended 2010 Stock Incentive Plan and Restated 2008 Equity Incentive Plan, as amended agree to datecomply with it and all applicable laws and regulations. PARTICIPANT DatePARTICIPANT: By: [ ] Address: Exhibit A NOTICE OF STOCK OPTION EXERCISE Date: Catabasis Pharmaceuticals1 Zipcar, Inc. Xxx Xxxxxxx 00 Xxxxx Xxxxxx, Suite B14202 CambridgeXxxxxx Xxxxx Xxxxxxxxx, MA 02139 XX 00000 Attention: Treasurer Dear Sir or Madam: I am the holder of an Incentive 2 Stock Option granted to me under the Catabasis Pharmaceuticals Zipcar, Inc. (the “Company”) Amended and Restated 2008 Equity 2010 Stock Incentive Plan, as amended to date, Plan on [ ] 3 for the purchase of [ ] 4 shares of Common Stock of the Company at an exercise a purchase price of $[ ] $ 5 per share. I hereby exercise my option to purchase 6 shares of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] 7 in the amount of 8. Please register my stock certificate as follows: Name(s): 9 Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing 10 1 Enter the Shares date of exercise. 2 Enter either “an Incentive” or “a Nonstatutory”. 3 Enter the date of grant. 4 Enter the total number of shares of Common Stock for my own account for investment only, and not with a view to, which the option was granted. 5 Enter the option exercise price per share of Common Stock. 6 Enter the number of shares of Common Stock to be purchased upon exercise of all or for sale in connection with, any distribution part of the Shares in violation option. 7 Enter “cash”, “personal check” or if permitted by the option or Plan, “stock certificates No. XXXX and XXXX”. 8 Enter the dollar amount (price per share of Common Stock times the Securities Act number of 1933 (the “Securities Act”shares of Common Stock to be purchased), or any rule the number of shares tendered. Fair market value of shares tendered, together with cash or regulation under check, must cover the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives purchase price of the Company such information as is necessary shares issued upon exercise. 9 Enter name(s) to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that appear on stock certificate: (ia) the Shares have not been registered under the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then availableYour name only; (iiib) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, Your name and other terms name (i.e., Xxxx Xxx and conditions Xxxx Xxx, Joint Tenants With Right of Rule 144 are complied withSurvivorship); and or (ivc) there is now no registration statement on file In the case of a Nonstatutory option only, a Child’s name, with the Securities and Exchange Commission with respect to any stock you as custodian (i.e., Xxxx Xxx, Custodian for Xxxxx Xxx). Note: There may be income and/or gift tax consequences of the Company and the Company has no obligation or current intention to register the Shares under the Securities Actregistering shares in a Child’s name. Very truly yours, (Signature10 Social Security Number of Holder(s).

Appears in 1 contract

Samples: Nonstatutory Stock Option Agreement (Zipcar Inc)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2016 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2016 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Provident Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Provident Bancorp, Inc. 2016 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $_______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ My check in the sum of $_______ and stock of the Company with a fair market value of $______, in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any minimum required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Incentive Stock Option Award Agreement (Provident Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the Univest Financial Corporation 2023 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 Univest Financial Corporation 2023 Equity Incentive Plan, as amended to datePlan and related prospectus. PARTICIPANT Date: By: [ ] Address: ____________________________________ Name:_______________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis PharmaceuticalsI, Inc. Xxx Xxxxxxx Xxxxxx______________________________, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals Inc. by Univest Financial Corporation (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Incentive Stock Option Agreement (the “Agreement”) and the Univest Financial Corporation 2023 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $________ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $____________, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $____________ in full/partial payment of the purchase price.* ___ My check in the sum of $___________ and stock of the Company with a fair market value of $______, in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any minimum required tax withholding). ___ Selling ___________ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, _____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 1933, as amended (the "Securities Act"), or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of shares you acquire through this Option exercise, the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act prior to your exercise of such Option. Date: _______________, 20___ _________________________________________ Participant’s signature * If I elect to exercise by xxxxxxxxxx shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Incentive Stock Option Award Agreement (UNIVEST FINANCIAL Corp)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2013 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2013 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: _______________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: (BY EMPLOYEE) I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Madison County Financial, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Madison County Financial, Inc. 2013 Equity Incentive Plan (the “Plan”) referred to therein, and notify you of my desire to purchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $_______ per share. I wish to pay the purchase price by (check one or more, as applicable): [Any payment to be delivered must accompany this Notice of Exercise of Option] ___ Cash or personal, certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A “net settlement” of the Option whereby I direct the Company to withhold a sufficient number of shares to satisfy the purchase price. ___ A check (personal, certified or cashier’s) in the sum of $_______ and stock of the Company with a fair market value of $______, in full payment of the purchase price.* ___ Please sell ______ shares from my Option shares through my broker in full/partial payment of the purchase price. If my broker requires additional forms in order to consummate this “broker cashless exercise,” I have included them with this election. I understand that after this exercise, ____________ shares of Common Stock remain subject to the Option, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby represent that it is my intention to acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Section 2(11) of the Securities Act of 1933) the shares you acquire through this Option exercise, the Company or transfer agent may require an opinion of counsel that such resale or distribution would not violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having been exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and treat them as if they are shares acquired by the option exercise. In addition, I will receive additional shares equal to the difference between the shares I constructively exchange and the total new option shares that I acquire. EXHIBIT B ACKNOWLEDGMENT OF RECEIPT OF SHARES I hereby acknowledge the delivery to me by Madison County Financial, Inc. (the “Company”) or its affiliate on _____________________________, of stock certificates for ____________________ shares of common stock of the Company purchased by me pursuant to the terms and conditions of the Stock Option Agreement and the Madison County Financial, Inc. 2013 Equity Incentive Plan, as amended applicable, which shares were transferred to date, me on [ ] for the purchase of [ ] shares of Common Stock of the Company at an exercise price of $[ ] per share. I hereby exercise my option to purchase shares of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation of the Securities Act of 1933 (the “Securities Act”), or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company’s stock record books on ____________________. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have not been registered under the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)Date:______________________ __________________________

Appears in 1 contract

Samples: Equity Incentive Plan (Madison County Financial, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2013 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2013 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: _______________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: (BY EMPLOYEE) I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Xxxxxxxx Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Xxxxxxxx Bancorp, Inc. 2013 Equity Incentive Plan (the “Plan”) referred to therein, and notify you of my desire to purchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $_______ per share. I wish to pay the purchase price by (check one or more, as applicable): [Any payment to be delivered must accompany this Notice of Exercise of Option] ___ Cash or personal, certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A “net settlement” of the Option whereby I direct the Company to withhold a sufficient number of shares to satisfy the purchase price. ___ A check (personal, certified or cashier’s) in the sum of $_______ and stock of the Company with a fair market value of $______, in full payment of the purchase price.* ___ Please sell ______ shares from my Option shares through my broker in full/partial payment of the purchase price. If my broker requires additional forms in order to consummate this “broker cashless exercise,” I have included them with this election. I understand that after this exercise, ____________ shares of Common Stock remain subject to the Option, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby represent that it is my intention to acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Section 2(11) of the Securities Act of 1933) the shares you acquire through this Option exercise, the Company or transfer agent may require an opinion of counsel that such resale or distribution would not violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having been exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and treat them as if they are shares acquired by the option exercise. In addition, I will receive additional shares equal to the difference between the shares I constructively exchange and the total new option shares that I acquire. EXHIBIT B ACKNOWLEDGMENT OF RECEIPT OF SHARES I hereby acknowledge the delivery to me by Xxxxxxxx Bancorp, Inc. (the “Company”) or its affiliate on _____________________________, of stock certificates for ____________________ shares of common stock of the Company purchased by me pursuant to the terms and conditions of the Stock Option Agreement and the Xxxxxxxx Bancorp, Inc. 2013 Equity Incentive Plan, as amended applicable, which shares were transferred to date, me on [ ] for the purchase of [ ] shares of Common Stock of the Company at an exercise price of $[ ] per share. I hereby exercise my option to purchase shares of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation of the Securities Act of 1933 (the “Securities Act”), or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company’s stock record books on ____________________. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have not been registered under the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)Date: __________________________ ________________________________

Appears in 1 contract

Samples: 2013 Equity Incentive Plan (Hamilton Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2017 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 's 2017 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: ____________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the "Option") granted to me under the Catabasis Pharmaceuticals by New Bancorp, Inc. (the "Company") Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the "Agreement") and the New Bancorp, Inc. 2017 Equity Incentive Plan (the "Plan") referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company ("Common Stock") for a purchase price of $______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier's check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act1933 prior to your exercise of such Option. Date: ____________, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act_____. Very truly yours, (Signature)_________________________________________ Participant's signature

Appears in 1 contract

Samples: Equity Incentive Plan (New Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The As of the date of grant of this Option set forth above, the undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2019 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2019 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: EXHIBIT A NOTICE OF EXERCISE OF NON-QUALIFIED STOCK OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by CBM Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the CBM Bancorp, Inc. 2019 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for an aggregate purchase price of $______ per share. I elect to pay the exercise price by: Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any required tax withholding). Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock remain subject to the Option, subject to all terms and provisions set forth in the Agreement and the Plan. ____________, 20___. _________________________________________________ Date Participant’s signature * If I elect to exercise an Option by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company at an exercise price with a statement attesting to the number of $[ ] per shareshares owned that will be treated as having been exchanged. I hereby exercise my option to purchase will keep the shares of Common Stock (the “Shares”), for which that I have enclosed [insert method of payment] in the amount of . Please register my stock certificate already own and treat them as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation of the Securities Act of 1933 (the “Securities Act”), or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have not been registered under the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Acttotal new option shares that I acquire. Very truly yours, (Signature)BY THE COMPANY

Appears in 1 contract

Samples: Non Qualified Stock Option Award Agreement (CBM Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2014 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2014 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: _______________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: (BY OUTSIDE DIRECTOR) I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Georgetown Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Georgetown Bancorp, Inc. 2014 Equity Incentive Plan (the “Plan”) referred to therein, and notify you of my desire to purchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $______ per share. I elect to pay the exercise price by (check one): ___ Cash or personal, certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any minimum required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock remain subject to the Option, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby represent that it is my intention to acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Section 2(11) of the Securities Act of 1933) the shares you acquire through this Option exercise, the Company or transfer agent may require an opinion of counsel that such resale or distribution would not violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and treat them as if they are shares acquired by the option exercise. In addition, I will receive additional shares equal to the difference between the shares I constructively exchange and the total new option shares that I acquire. EXHIBIT B ACKNOWLEDGMENT OF RECEIPT OF SHARES I hereby acknowledge the delivery to me by Georgetown Bancorp, Inc. (the “Company”) or its affiliate on _____________________________, of stock certificates for ____________________ shares of common stock of the Company purchased by me pursuant to the terms and conditions of the Stock Option Agreement and the Georgetown Bancorp, Inc. 2014 Equity Incentive Plan, as amended applicable, which shares were transferred to date, me on [ ] for the purchase of [ ] shares of Common Stock of the Company at an exercise price of $[ ] per share. I hereby exercise my option to purchase shares of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation of the Securities Act of 1933 (the “Securities Act”), or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company’s stock record books on ____________________. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have not been registered under the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)Date:__________________ ___________________

Appears in 1 contract

Samples: 2014 Equity Incentive Plan (Georgetown Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2016 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2016 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: ____________________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Provident Bancorp, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Provident Bancorp, Inc. 2016 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ My check in the sum of $_______ and stock of the Company with a fair market value of $______, in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any minimum required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Non Qualified Stock Option Award Agreement (Provident Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2011 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2011 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: Participant EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: (BY OUTSIDE DIRECTORS) I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Northwest Bancshares, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Northwest Bancshares, Inc. 2011 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $_________ per share. Enclosed please find (check one): ___ Cash, on [ ] for personal, certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ My check in the sum of $_______ and stock of the Company with a fair market value of $______, in full/partial payment of the purchase price.* ___ Please sell ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed 1933 prior to your exercise of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Actsuch Option. Very truly yours, (Signature).

Appears in 1 contract

Samples: 2011 Equity Incentive Plan (Northwest Bancshares, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2017 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 's 2017 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: _____________________________________ EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: I am hereby exercise the holder of an Incentive Stock Option stock option (the "Option") granted to me under the Catabasis Pharmaceuticals by Best Hometown Bancorp, Inc. (the "Company") Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the "Agreement") and the Best Hometown Bancorp, Inc. 2017 Equity Incentive Plan (the "Plan") referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company ("Common Stock") for a purchase price of $______ per share. I elect to pay the exercise price by: ___ Cash or personal, on [ ] for certified or cashier's check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act and are “restricted securities” within the meaning of Rule 144 under the Securities Act1933 prior to your exercise of such Option. Date: ____________, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless they are subsequently registered under the Securities Act or an exemption from registration is then available; (iii) in any event, the exemption from registration under Rule 144 will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with the Securities and Exchange Commission with respect to any stock of the Company and the Company has no obligation or current intention to register the Shares under the Securities Act_____. Very truly yours, (Signature)_________________________________________ Participant's signature

Appears in 1 contract

Samples: Non Qualified Stock (Best Hometown Bancorp, Inc.)

PARTICIPANT’S ACCEPTANCE. The undersigned hereby accepts the foregoing option Option and agrees to the terms and conditions thereofhereof, including the terms and provisions of the 2015 Equity Incentive Plan. The undersigned hereby acknowledges receipt of a copy of the Company’s Amended and Restated 2008 2015 Equity Incentive Plan, as amended to date. PARTICIPANT Date: By: [ ] Address: EXHIBIT A NOTICE OF STOCK EXERCISE OF OPTION EXERCISE Date: Catabasis Pharmaceuticals, Inc. Xxx Xxxxxxx Xxxxxx, Suite B14202 Cambridge, MA 02139 Attention: Treasurer Dear Sir or Madam: (BY OUTSIDE DIRECTOR) I am hereby exercise the holder of an Incentive Stock Option stock option (the “Option”) granted to me under the Catabasis Pharmaceuticals by Waterstone Financial, Inc. (the “Company”) Amended or its affiliate, subject to all the terms and Restated 2008 provisions set forth in the Stock Option Agreement (the “Agreement”) and the Waterstone Financial, Inc. 2015 Equity Incentive Plan (the “Plan”) referred to therein, as amended and notify you of my desire to datepurchase __________________ shares of common stock of the Company (“Common Stock”) for a purchase price of $______ per share. I elect to pay the exercise price by (check one): ___ Cash or personal, on [ ] for certified or cashier’s check in the sum of $_______, in full/partial payment of the purchase price. ___ Stock of [ ] the Company with a fair market value of $______ in full/partial payment of the purchase price.* ___ A net settlement of the Option, using a portion of the shares obtained on exercise in payment of the exercise price of the Option (and, if applicable, any minimum required tax withholding). ___ Selling ______ shares from my Option shares through a broker in full/partial payment of the purchase price. I understand that after this exercise, ____________ shares of Common Stock of remain subject to the Company at an exercise price of $[ ] per shareOption, subject to all terms and provisions set forth in the Agreement and the Plan. I hereby exercise represent that it is my option intention to purchase acquire these shares for the following purpose: ___ investment ___ resale or distribution Please note: if your intention is to resell (or distribute within the meaning of Common Stock (the “Shares”), for which I have enclosed [insert method of payment] in the amount of . Please register my stock certificate as follows: Name(s): Address: Tax I.D. #: I represent, warrant and covenant as follows: I am purchasing the Shares for my own account for investment only, and not with a view to, or for sale in connection with, any distribution of the Shares in violation Section 2(11) of the Securities Act of 1933 (1933) the “Securities Act”)shares you acquire through this Option exercise, or any rule or regulation under the Securities Act. I have had such opportunity as I have deemed adequate to obtain from representatives of the Company or transfer agent may require an opinion of counsel that such information as is necessary to permit me to evaluate the merits and risks of my investment in the Company. I have sufficient experience in business, financial and investment matters to be able to evaluate the risks involved in the purchase of the Shares and to make an informed investment decision with respect to such purchase. I can afford a complete loss of the value of the Shares and am able to bear the economic risk of holding such Shares for an indefinite period. I understand that (i) the Shares have resale or distribution would not been registered under violate the Securities Act of 1933 prior to your exercise of such Option. Date: ____________, _____. _________________________________________ Participant’s signature * If I elect to exercise by exchanging shares I already own, I will constructively return shares that I already own to purchase the new option shares. If my shares are in certificate form, I must attach a separate statement indicating the certificate number of the shares I am treating as having exchanged. If the shares are held in “street name” by a registered broker, I must provide the Company with a notarized statement attesting to the number of shares owned that will be treated as having been exchanged. I will keep the shares that I already own and are “restricted securities” within the meaning of Rule 144 under the Securities Act, (ii) the Shares cannot be sold, transferred or otherwise disposed of unless treat them as if they are subsequently registered under shares acquired by the Securities Act or an exemption from registration is then available; (iii) in any eventoption exercise. In addition, the exemption from registration under Rule 144 I will not be available for at least six months and even then will not be available unless a public market then exists for the Common Stock, adequate information concerning the Company is then available receive additional shares equal to the public, and other terms and conditions of Rule 144 are complied with; and (iv) there is now no registration statement on file with difference between the Securities and Exchange Commission with respect to any stock of the Company shares I constructively exchange and the Company has no obligation or current intention to register the Shares under the Securities Act. Very truly yours, (Signature)total new option shares that I acquire.

Appears in 1 contract

Samples: Equity Incentive Plan (Waterstone Financial, Inc.)

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