Severance Payment Form

SEVERANCE PAYMENT FORM

Parties and Identifying Information

Employment termination date:    Employee ID or last 4 SSN:

Severance Payment Summary (Gross amounts)

Total gross severance payable under this Agreement:

Payment Method and Schedule

Payment method (select one): Check Direct deposit to account ending in

Form of payment: Lump sum    Installments

If installments: Number of installments ; Frequency ; First payment date

Taxes, Withholding and Deductions

Employer will withhold federal, state and local taxes and other lawful deductions from payments as required. Employee acknowledges that the net payment set forth above is after applicable withholdings and that Employee is responsible for any taxes not withheld by Employer to the extent required by law.

Estimated total tax withholding:

Conditions Precedent to Payment

The obligation of Employer to make the payments described in this Form is conditioned upon Employee signing and delivering the Release and any related documentation specified by Employer by the deadline below, and returning all Company property in Employee's possession. Employer may withhold payment until these conditions are satisfied.

Employee confirms all Company property has been returned: Yes    No

Release, Waiver and Consideration

In consideration of the payments and benefits described above, and other good and valuable consideration, Employee knowingly and voluntarily releases and forever discharges Employer, its affiliates, predecessors, successors, subsidiaries, and their respective officers, directors, employees and agents (collectively, Released Parties) from any and all claims, demands, causes of action, liabilities or rights of action, known or unknown, arising out of or related to Employee's employment with or separation from Employer through the Effective Date of this Agreement, except for rights that by law cannot be waived. This release includes claims under federal, state or local statutes, common law, contract, tort, and equity to the fullest extent permitted by law.

Employee acknowledges that the consideration provided by Employer is in addition to any amounts to which Employee may otherwise be entitled and that the payments are subject to the conditions set forth herein. If Employee revokes the Release within any statutory revocation period applicable to the Release, Employer's obligation to pay may be void or subject to adjustment as required by law.

Confidentiality, Non‑Disparagement and Cooperation

Employee agrees to keep the terms and amount of this Agreement confidential, except as required by law, tax reporting obligations, or to Employee's legal or financial advisors. Employee further agrees not to make any public statements that disparage Employer or its representatives. Employee will reasonably cooperate with Employer after separation in connection with matters that arose during Employee's employment, subject to reimbursement of reasonable expenses.

Employee initial to confirm acceptance of confidentiality and non-disparagement terms:

Miscellaneous

This Form constitutes the entire agreement between the parties regarding the severance payment described herein. Any modification must be in writing signed by both parties. If any provision is held invalid, the remainder shall continue in full force and effect. The parties acknowledge that this Form does not create a contract of employment or continued employment.

Acknowledgement and Certification

By signing below, Employee certifies that Employee has read this Form in full, understands its terms, and accepts the severance payment and related conditions set forth herein. Employee further certifies that the information provided on this Form is true and correct to the best of Employee's knowledge.

Employee acknowledges whether Employee has consulted with an attorney regarding this Form: Yes No

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