XM Radio 2009 Annual Report Download - page 98
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Form of Reverse Side of Rights Certificate — continued
FORM OF ELECTION TO PURCHASE
(To be executed if holder desires to exercise the Rights Certificate)
To Sirius XM Radio Inc.:
The undersigned hereby irrevocably elects to exercise Rights represented by this Rights Certificate
to purchase the number of one-millionths of a Preferred Share or other securities issuable upon the exercise of
such Rights and requests that certificates for such securities be issued in the name of and delivered to:
Please insert social security or other identifying number:
(Please print name and address)
If such number of Rights is not all the Rights evidenced by this Rights Certificate, a new Rights Certificate
for the balance remaining of such Rights will be registered in the name of and delivered to:
Please insert social security or other identifying number:
(Please print name and address)
Dated: ,
Signature
Signature(s) Guaranteed:
SIGNATURE(S) SHOULD BE GUARANTEED BY AN ELIGIBLE GUARANTOR INSTITUTION (BANKS,
STOCKBROKERS, SAVINGS AND LOAN ASSOCIATIONS AND CREDIT UNIONS WITH MEMBER-
SHIP IN AN APPROVED SIGNATURE GUARANTEE MEDALLION PROGRAM), PURSUANT TO S.E.C.
RULE 17Ad-15.
The undersigned hereby certifies that the Rights evidenced by this Rights Certificate are not beneficially
owned by an Acquiring Person or an Affiliate or Associate thereof (as defined in the Rights Agreement).
Signature
A-39