In consideration of the love and affection of my spouse, [SPOUSE'S NAME], and for other valuable consideration, I, [TRANSFEROR'S NAME], hereby give, assign, and transfer to [SPOUSE'S NAME], Certificate No. [NUMBER], representing [NUMBER] shares of common stock in [CORPORATION'S NAME], a [STATE] corporation, together with full authority to have said certificate transferred upon the books and records of said corporation.

Date:

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TRANSFEROR'S SIGNATURE

[SPOUSE'S NAME] hereby acknowledges receipt of the shares of common stock described above.

Date:

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SPOUSE'S SIGNATURE