commonform.org / ironsides / 83b-election / 1e4d
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Contents

  1. (No Heading)
    1. Name of Taxpayer
    2. Name of Spouse
    3. Address
    4. Identification Number of Taxpayer
    5. Identification Number of Spouse
    6. Taxable Year

The undersigned taxpayer hereby elects, pursuant to Section 83(b) of the Internal Revenue Code, to include in taxpayer's gross income for the current taxable year, the amount of any compensation taxable to taxpayer in connection with taxpayer's receipt of the property described below:

The name, address, taxpayer identification number and taxable year of the undersigned are as follows:

Name of Taxpayer

Name of Spouse

Address

Identification Number of Taxpayer

Identification Number of Spouse

Taxable Year

The property with respect to which the election is made is described as follows:

shares of the Common Stock of , a Delaware corporation (the Company).

The date on which the property was transferred is:

The property is subject to the following restrictions:

Repurchase option at cost in favor of the Company upon termination of taxpayer's employment or consulting relationship.

The fair market value at the time of transfer, determined without regard to any restriction other than a restriction which by its terms will never lapse, of such property is: .

The amount (if any) paid for such property: Paid for with property having a value of and equivalent to the value of the Shares.

The undersigned has submitted a copy of this statement to the person for whom the services were performed in connection with the undersigned's receipt of the above-described property. The transferee of such property is the person performing the services in connection with the transfer of said property.

The undersigned understands that this election may not be revoked except with the consent of the Commissioner.