Exhibit 10.12.2
VENTAS EXECUTIVE DEFERRED STOCK
COMPENSATION PLAN
[YEAR] DEFERRAL ELECTION
FORM
To the Corporate
Secretary:
Pursuant to Article 6 of the Ventas
Executive Deferred Stock Compensation Plan (the
“Plan”), I hereby elect to have (select
one):
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¨
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percent
( %)
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¨
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$
dollars
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of my (select one or
both):
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¨
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base salary per
pay period
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¨
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bonus
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payable hereafter deferred and
credited to a Stock Unit Account for me, net of any required FICA
or other withholdings. I understand that I may revoke or modify
this election only with respect to amounts payable on or after the
first day of a subsequent calendar year and only by filing a new
election form before the first day of such subsequent calendar year
in accordance with Plan procedures.
I elect to have dividend equivalents
with respect to Stock Units in my Stock Unit Account (select
one):
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¨
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paid to me in
cash as soon as practicable after dividends are paid on shares of
Ventas, Inc.
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¨
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converted to
additional Stock Units and distributed at the time and in the
manner selected for my Stock Unit Account.
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I direct that distribution of my
Stock Unit Account be made after my Termination of Employment as
follows (select one):
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¨
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a lump
sum.
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¨
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a series of
annual payments over
years (10 or less, not to extend more than 10 years after my
Termination of Employment).
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I direct that distribution of my
Stock Unit Account commence as soon as administratively feasible
after (select one):
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¨
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my Termination
of Employment occurs.
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¨
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January 1
of the calendar year immediately following my Termination of
Employment.
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¨
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seven months
following my Termination of Employment.
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¨
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.
(select date)
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Change in Control Accelerated
Payment (select if desired):
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