NTL Incorporated Beneficial Owner Election Form for Rights Offering
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Summary
This form allows beneficial owners of NTL Incorporated to elect whether to exercise, sell, or decline transferable rights to purchase shares of the company's common stock. Owners can specify the number of shares they wish to buy, make payment arrangements, and must confirm they have read the related prospectus. The form also requires a declaration of residency status and agreement to the terms. If payment is not made, the company may pursue legal remedies. The form must be signed by the beneficial owner or their authorized representative.
EX-4.17 7 y89596a1exv4w17.txt EXHIBIT 4.17 EXHIBIT 4.17 BENEFICIAL OWNER ELECTION FORM I (we) acknowledge receipt of your letter and the enclosed materials relating to the grant of transferable rights to purchase shares of common stock, par value $0.01 per share, of NTL Incorporated (the "Company"). I (we) hereby instruct you as follows. (CHECK THE APPLICABLE BOXES AND PROVIDE ALL REQUIRED INFORMATION) [ ] Please exercise my (our) rights for shares of common stock as set forth below:
I am (we are) making the total purchase price payment required in the following manner: [ ] Payment in the following amount is enclosed: $________; or [ ] Please deduct payment of $________ from the following account maintained by you as follows: (The total of the above two boxes must equal the total purchase price specified on line "C" above.) ------------------------------ ------------------------------ Type of Account Account No. I (we) on my (our) own behalf, or on behalf of any person(s) on whose behalf, or under whose directions, I am (we are) signing this form: - acknowledge that I (we) received and read the prospectus relating to my (our) rights and that the terms and conditions of the rights as set forth in the prospectus have been incorporated by reference into this form; - irrevocably elect to purchase the number of shares of common stock indicated above upon the terms and conditions specified in the prospectus; - represent and warrant that I am a (we are) resident(s) of the United States or am (are) otherwise entitled to exercise, or direct the exercise of, my (our) rights as a non-U.S. holder falling within the permitted categories of persons described in the prospectus; and - agree that if I (we) fail to pay for the shares of common stock I (we) have elected to purchase, you may exercise any remedies available to you under law.
Name of beneficial owner(s): - ------------------------------------------------------------ - ------------------------------------------------------------ Signature of beneficial owner(s): - ------------------------------------------------------------ - ------------------------------------------------------------ If you are signing in your capacity as a trustee, executor, administrator, guardian, attorney-in-fact, agent, officer of a corporation or another acting in a fiduciary or representative capacity, please provide the following information: Name: - ---------------------------------------------------- Capacity: - ------------------------------------------------- Address (including Zip Code): - -------------------------- - ------------------------------------------------------------ - ------------------------------------------------------------ Telephone Number: - --------------------------------------
