1.

Award of Restricted Stock Units. The Company hereby grants to Participant a total of «Txt_Nbr_of_Shares» («Whole_Nbr_of_Shares») restricted stock units (the “Units”). Each Unit represents a right to receive one share of Common Stock (a “Share”) on the applicable RSU Vesting Date subject to the terms and conditions set forth in this Award Agreement including any appendix hereto (the “Appendix”; the Agreement and the Appendix, collectively, the “Award Agreement”), and subject to adjustment as provided in the Plan. The Units are granted pursuant to the Plan and are subject to all of the terms and conditions of the Plan.

2.

Restrictions. The Units are being awarded to Participant subject to the transfer and forfeiture conditions set forth below (the “Restrictions”). In its sole discretion, the Committee may amend or waive the provisions of subparagraphs (b) or (c) hereof, in whole or in part, to the extent necessary or advisable to comply with applicable laws, as determined by the Committee:

a.

No Assignment. Unless otherwise provided by the Committee, prior to the vesting of the Units as described in Section 3 below, Participant may not directly or indirectly, by operation of law or otherwise, voluntarily or involuntarily, sell, assign, pledge, encumber, charge or otherwise transfer any of the Units still subject to Restrictions. The Units shall be forfeited if Participant violates or attempts to violate these transfer Restrictions.

b.

Restricted Conduct. If Participant engages in any of the conduct described in subparagraphs (i) through (v) below for any reason, in addition to all remedies in law and/or equity available to the Company or any Affiliate, including the recovery of liquidated damages, Participant shall forfeit all Units (whether or not vested) and shall immediately pay to the Company, with respect to previously vested Units, an amount equal to (x) the per share Fair Market Value of the Shares on the date on which the Shares were issued with respect to the applicable previously vested Units times (y) the number of Shares underlying such previously vested Units, without regard to any Tax-Related Items (as defined below) that may have been deducted from such amount. For purposes of subparagraphs (i) through (v) below, “Company” shall mean Motorola Mobility Holdings, Inc. and/or any of its Affiliates.

(i)

Confidential Information. During the course of Participant’s employment with the Company or any Affiliate and thereafter, Participant uses or discloses, except on behalf of the Company and pursuant to the Company’s directions, any Company Confidential Information (as defined in Section 22 below); and/or

(ii)

Solicitation of Employees. During Participant’s employment and for a period of one year following the termination of Participant’s employment for any reason, Participant hires, recruits, solicits or induces, or causes, allows, permits or aids others to hire, recruit, solicit or induce, or to communicate in support of those activities, any employee of the Company who possesses Confidential Information of the Company to terminate his/her employment with the Company and/or to seek employment with Participant’s new or prospective employer, or any other company; and/or

(iii)

Solicitation of Customers. During Participant’s employment and for a period of one year following the termination of Participant’s employment for any reason, Participant, directly or indirectly, on behalf of Participant or any other person, company or entity, solicits or participates in soliciting, products or services competitive with or similar to products or services offered by, manufactured by, designed by or distributed by the Company to any person, company or entity which was a customer or potential customer for such products or services and with which Participant had direct or indirect contact regarding those products or services or about which Participant learned Confidential Information at any time during the two years prior to Participant’s termination of employment with the Company; and/or

(iv)

Non-Competition regarding Products or Services. During Participant’s employment and for a period of one year following the termination of Participant’s employment for any reason, Participant, directly or indirectly, in any capacity, provides products or services competitive with or similar to products or services offered by the Company to any person, company or entity which was a customer for such products or services and with which customer Participant had direct or indirect contact regarding those products or services or about which customer Participant learned Confidential Information at any time during the one year prior to Participant’s termination of employment with the Company; and/or

(v)

Non-Competition regarding Activities. During Participant’s employment and for a period of one year following the termination of Participant’s employment for any reason, Participant engages in activities which are entirely or in part the same as or similar to activities in which Participant engaged at any time during the one year preceding termination of Participant’s employment with the Company, for any person, company or entity in connection with products, services or technological developments (existing or planned) that are entirely or in part the same as, similar to, or competitive with, any products, services or technological developments (existing or planned) on which Participant worked at any time during the one year preceding termination of Participant’s employment. This paragraph applies in countries in which Participant has physically been present performing work for the Company at any time during the one year preceding termination of Participant’s employment.

c.

Recoupment Policy. If Participant is an officer subject to Section 16 of the Exchange Act the Units are subject to the terms and conditions of the Company’s Policy Regarding

Recoupment of Incentive Payments upon Financial Restatement (such policy, as it may be amended from time to time, the “Recoupment Policy”). The Recoupment Policy provides for determinations by the Company’s independent directors that, as a result of, in whole or in part, intentional fraud or misconduct by Participant, the Company’s financial results were restated or materially misstated (a “Policy Restatement”). In the event of a Policy Restatement, the Company’s independent directors may require, among other things (a) cancellation of any of the Units that remain outstanding; and/or (b) reimbursement of any gains in respect of the Units, if and to the extent the conditions set forth in the Recoupment Policy apply. Any determinations made by the independent directors in accordance with the Recoupment Policy shall be binding upon Participant. The Recoupment Policy is in addition to any other remedies which may be otherwise available at law, in equity or under contract, to the Company.

d.

Repayment/Forfeiture. Any benefits Participant may receive hereunder shall be subject to repayment or forfeiture as may be required to comply with the requirements of the U.S. Securities and Exchange Commission or any applicable law, including the requirements of the Dodd-Frank Wall Street Reform and Consumer Protection Act, or any securities exchange on which the Shares are traded, as may be in effect from time to time.

3.

Vesting. Subject to the remaining terms and conditions of this Award Agreement, and provided the Units have not been forfeited as described in Section 2 above, the Units will vest as follows:

a.

Vesting Period. The Units will vest as follows in accordance with the following schedule (the applicable date, the “RSU Vesting Date”):

(i)

<<To be determined at grant.>>

(ii)

The period from the Date of Grant through the last RSU Vesting Date set forth above is referred to as the “Restriction Period”. Any unvested Units shall be automatically forfeited upon Participant’s termination of employment with the Company or an Affiliate prior to the applicable RSU Vesting Date for any reason other than those set forth in Sections 3(b) through (e) below. The Company will not be obligated to pay Participant any consideration whatsoever for forfeited Units.

(iii)

If, during the Restriction Period, Participant takes a Leave of Absence (as defined in Section 22 below) from the Company or an Affiliate, the Units will continue to be subject to this Award Agreement. If the Restriction Period expires while Participant is on a Leave of Absence, Participant will be entitled to the Units even if Participant has not yet returned to active employment.

b.

Change in Control. If a Change in Control of the Company occurs and the successor or survivor corporation (or parent or subsidiary thereof) does not convert, assume or replace this Award, then immediately prior to the Change in Control, the Units shall be fully vested; provided, further, that with respect to any Award that is converted, assumed or replaced, such converted, assumed or replaced awards shall provide that the Award shall be fully vested for any Participant who is involuntarily terminated (for a reason other than “Cause”) or quits for “Good Reason” within 24 months of the Change in Control. For purposes of this paragraph, the term “Change in Control” is defined in the Plan and the terms “Cause” and “Good Reason” are defined in Section 22 below.

c.

Disability. All unvested Units shall fully vest upon Participant’s termination of employment with the Company and its Affiliates due to Disability (as defined in the Plan).

d.

Death. All unvested Units shall fully vest upon Participant’s termination of employment with the Company and its Affiliates due to death.

e.

Certain Terminations of Employment. In the case of Termination due to a Divestiture (as defined in Section 22 below) and the Units are not assumed by Participant’s successor employer, or a parent or subsidiary thereof or replaced with an award at least comparable to these Units, or in the event of Participant’s Layoff (as defined in Section 22 below) before the expiration of the Restriction Period, and if the Units have not been forfeited as described in Section 2 above, then the Units shall vest on a pro rata basis in an amount equal to (a)(i) the total number of Units subject to this Award, multiplied by (ii) a fraction, the numerator of which is the number of completed full months of service by Participant from the Date of Grant to the employee’s date of termination and the denominator of which is the Restriction Period, minus (b) any Units that vested prior to such Termination. Any Units remaining unvested at the date of such Divestiture or Layoff shall be forfeited.

4.

Delivery of Shares.

a.

Upon the vesting of the applicable Units described in Section 3 above, the Company shall establish a brokerage account for Participant and credit to that account the number of Shares equal to the number of Units that have vested, less any Tax-Related Items (as defined in Section 8 below). Unless otherwise determined by the Committee, the Company shall not deliver to Participant certificates evidencing Shares issued in connection with the vested Units.

b.

Subject to Section 26 the actions contemplated by subparagraph (a) above shall occur within 60 days following the date that the applicable Units vested.

5.

Whole Shares. All Awards shall be paid in whole Shares; no fractional Shares shall be credited or delivered to Participant.

6.

Adjustments. The Units shall be subject to adjustment as provided in Section 12.1 of the Plan.

7.

Dividends. No dividends (or dividend equivalents) shall be paid with respect to Units credited to Participant’s account.

8.

Responsibility for Taxes. Regardless of any action the Company or Participant’s Employer (the “Employer”) takes with respect to any or all income tax, social insurance, payroll tax, payment on account or other tax-related items related to Participant’s participation in the Plan and legally applicable to Participant (“Tax-Related Items”), Participant acknowledges that the ultimate liability for all Tax-Related Items is and remains Participant’s responsibility and may exceed the amount actually withheld by the Company or the Employer. Participant further acknowledges that the Company and/or the Employer (i) make no representations or undertakings regarding the treatment of any Tax-Related Items in connection with any aspect of the Units, including, but not limited to, the grant, vesting or settlement of the Units, the issuance of Shares upon settlement of the Units, the subsequent sale of Shares acquired pursuant to such issuance and the receipt of any dividends; and (ii) do not commit to and are under no obligation to structure the terms of the grant or any aspect of the Units to reduce or eliminate Participant’s liability for Tax-Related Items or

achieve any particular tax result. Further, if Participant has become subject to tax in more than one jurisdiction between the Date of Grant and the date of any relevant tax withholding event, Participant acknowledges that the Company and/or the Employer (or former employer, as applicable) may be required to withhold or account for Tax-Related Items in more than one jurisdiction.

9.

Stockholder Rights. Participant shall have no rights as a stockholder of the Company in respect of the Units, including the right to vote or to receive cash dividends and other distributions until delivery of the Shares in satisfaction of the Units in accordance with Section 4 above.

10.

Funding. No assets or Shares shall be segregated or earmarked by the Company in respect of any Units awarded hereunder. The grant of Units hereunder shall not constitute a trust and shall be solely for the purpose of recording an unsecured contractual obligation of the Company.

11.

Acknowledgement of Discretionary Nature of the Plan; No Vested Rights. By accepting the Units, Participant acknowledges, understands, and agrees that: (i) the Plan is established voluntarily by the Company, is discretionary in nature, and may be modified, amended, suspended or terminated by the Company at any time; (ii) the grant of the Units is voluntary and occasional and does not create any contractual or other right to receive future restricted stock units, or benefits in lieu of restricted stock units, even if Units have been granted repeatedly in the

past; (iii) all decisions with respect to future awards, if any, will be at the sole discretion of the Company; (iv) Participant’s acceptance of the Units and participation under the Plan is voluntary; (v) Participant’s participation in the Plan shall not create a right to further employment with the Employer and shall not interfere with the ability of the Employer to terminate Participant’s employment at any time; (vi) the grant of the Units and Participant’s participation in the Plan shall not be interpreted to form an employment contract or relationship with the Company or any Affiliate; and (vii) no claim or entitlement to compensation or damages shall arise from forfeiture of any portion of the Units resulting from termination of Participant’s employment by the Company or the Employer (for any reason whatsoever and regardless of whether in breach of local labor laws) and, in consideration of the grant of the Units, to which Participant is otherwise not entitled, Participant irrevocably agrees never to institute any claim against the Company or the Employer, waives Participant’s ability, if any, to bring any such claim, and releases the Company and the Employer from any such claim that may arise; if, notwithstanding the foregoing, any such claim is allowed by a court of competent jurisdiction, then, by participating in the Plan, Participant shall be deemed irrevocably to have agreed not to pursue such claim and agrees to execute any and all documents necessary to request dismissal or withdrawal of such claim.

12.

No Relation to Other Benefits/Termination Indemnities. Participant acknowledges that he or she has entered into employment with the Company or an Affiliate upon terms that did not include this Award or similar awards, that his or her decision to continue employment is not dependent on an expectation of this Award or similar awards, and that any amount received under this Award is considered an amount in addition to that which Participant expects to be paid for the performance of his or her services. Thus, the Units and the Shares subject to the Units are not part of normal or expected compensation or salary for any purpose, including, without limitation, calculating any severance, resignation, termination, redundancy, dismissal, end-of-service payments, bonuses, long-service awards, pension or retirement or welfare benefits or similar payments, notwithstanding any provision of any compensation, insurance agreement or benefit plan to the contrary. Further, the Units and the Shares subject to the Units are not intended to replace any pension rights. In the event the Company is not the Employer, the Units and the Shares subject to the Units are extraordinary items that do not constitute compensation of any kind for services of any kind rendered to the Company or the Employer, which are outside the scope of Participant’s employment contract, if any and in no event should be considered as compensation for, or relating in any way to, past services for the Company, the Employer or any Affiliate.

13.

No Advice Regarding Grant. The Company is not providing any tax, legal or financial advice, nor is the Company making any recommendations regarding Participant’s participation in the Plan, or Participant’s acquisition or sale of the Shares underlying the Units. Participant should note that the future value of the Shares underlying the Units is unknown. Participant is hereby advised to consult with Participant’s own personal tax, legal, and financial advisors regarding Participant’s participation in the Plan before taking any action related to the Plan.

14.

Acknowledgements. With respect to the subject matter of subparagraphs 2(b) (i) through (v) and Sections 20 and 21 hereof, this Award Agreement is the entire agreement with the Company. No waiver of any breach of any provision of this Award Agreement by the Company shall be construed to be a waiver of any succeeding breach or as a modification of such provision. The provisions of this Award Agreement shall be severable and in the event that any provision of this Award Agreement shall be found by any court as specified in Section 21 below to be unenforceable, in whole or in part, the remainder of this Award Agreement shall nevertheless be enforceable and binding on the parties. Participant hereby agrees that the court may modify any

invalid, overbroad or unenforceable term of this Award Agreement so that such term, as modified, is valid and enforceable under applicable law. Further, by accepting any Award under this Award Agreement, Participant affirmatively states that she or he has not, will not and cannot rely on any representations not expressly made herein.

15.

The Company Assignment Rights. The Company shall have the right to assign this Award Agreement, which shall not affect the validity or enforceability of this Award Agreement. This Award Agreement shall inure to the benefit of assigns and successors of the Company.

16.

Waiver. The failure of the Company to enforce at any time any provision of this Award Agreement shall in no way be construed to be a waiver of such provision or any other provision hereof.

17.

Actions by the Committee. The Committee may delegate its authority to administer this Award Agreement. The actions and determinations of the Committee or its delegate shall be binding upon the parties.

18.

Agreement Following Termination of Employment.

a.

Participant agrees that upon termination of employment with the Company or an Affiliate, Participant will immediately inform the Company of: (i) the identity of any new employer (or the nature of any start-up business or self-employment); (ii) Participant’s new title; and (iii) Participant’s job duties and responsibilities.

b.

Participant hereby authorizes the Company or an Affiliate to provide a copy of this Award Agreement to Participant’s new employer. Participant further agrees to provide information to the Company or an Affiliate as may from time to time be requested in order to determine his or her compliance with the terms hereof.

19.

Consent to Transfer Personal Data. By accepting the Award, Participant voluntarily acknowledges and consents to the collection, use, processing and transfer of personal data, in electronic or other form, as described in this Award Agreement. Participant is not obliged to consent to such collection, use, processing and transfer of personal data. However, failure to provide the consent may affect Participant’s ability to participate in the Plan. The Company, its Affiliates and Participant’s Employer hold certain personal information about Participant, that may include Participant’s name, home address and telephone number, date of birth, social security number or other employee identification number, salary, salary grade, hire date, nationality, job title, any shares of stock held in the Company, or details of all restricted stock units or any other entitlement to shares of stock awarded, canceled, purchased, vested, or unvested, for the exclusive purpose of implementing, administering, and managing the Plan (“Data”). The Company and/or its Affiliates will transfer Data among themselves as necessary for the purpose of implementation, administration and management of Participant’s participation in the Plan, and the Company and/or any of its Affiliates may each further transfer Data to any third parties assisting the Company in the implementation, administration and management of the Plan. These recipients may be located throughout the world, including the United States and the recipients’ country may have different data privacy laws and protections from Participant’s country. Participant authorizes the Data recipients to receive, possess, use, retain and transfer the Data, in electronic or other form, for the purposes of implementing, administering and managing Participant’s participation in the Plan, including any requisite transfer of such Data as may be required for the administration of the Plan and/or the subsequent holding of Shares on Participant’s behalf to a broker or other third party with whom Participant may elect to deposit any Shares acquired pursuant to the Plan.

Participant may request a list with the names and addresses of any potential recipients of the Data by contacting Participant’s local human resources representative or the Company. Participant may, at any time, review Data, require any necessary amendments to it or withdraw the consents herein in writing, in any case without cost, by contacting Participant’s local human resources representative the Company; however, withdrawing Participant’s consent may affect Participant’s ability to participate in the Plan.

20.

Remedies for Breach. Participant hereby acknowledges that the harm caused to the Company by the breach or anticipated breach of subparagraphs 2(b) (i), (ii), (iii), (iv) and/or (v) of this Award Agreement will be irreparable and further agrees the Company may obtain injunctive relief against Participant in addition to and cumulative with any other legal or equitable rights and remedies the Company may have pursuant to this Award Agreement, any other agreements between Participant and the Company for the protection of the Company’s Confidential Information or law, including the recovery of liquidated damages. Participant agrees that any interim or final equitable relief entered by a court of competent jurisdiction, as specified in Section 21 below, will, at the request of the Company, be entered on consent and enforced by any such court having jurisdiction over Participant. This relief would occur without prejudice to any rights either party may have to appeal from the proceedings that resulted in any grant of such relief.

21.

Governing Law. All questions concerning the construction, validity and interpretation of this Award shall be governed by and construed according to the law of the State of Delaware without regard to any state’s conflicts of law principles. Any and all disputes relating to, concerning or arising from this Award Agreement, or relating to, concerning or arising from the relationship between the parties evidenced by the Award or this Award Agreement, shall be brought and heard exclusively in the United States District Court for the District of New Delaware or the Delaware Superior Court, New Castle County. Each of the parties hereby represents and agrees that such party is subject to the personal jurisdiction of said courts; hereby irrevocably consents to the jurisdiction of such courts in any legal or equitable proceedings related to, concerning or arising from such dispute; and waives, to the fullest extent permitted by law, any objection which such party may now or hereafter have that the laying of the venue of any legal or equitable proceedings related to, concerning or arising from such dispute which is brought in such courts is improper or that such proceedings have been brought in an inconvenient forum.

22.

Definitions. Any capitalized terms used herein that are not otherwise defined below or elsewhere in this Award Agreement shall have the meaning provided under the Plan.

a.

“Cause” means, with respect to any Participant, (i) Participant’s conviction of any criminal violation involving dishonesty, fraud or breach of trust or (ii) Participant’s willful engagement in gross misconduct in the performance of Participant’s duties that materially injures the Company or an Affiliate.

b.

“Confidential Information” means information concerning the Company and its business that is not generally known outside the Company, and includes (a) trade secrets; (b) intellectual property; (c) the Company’s methods of operation and Company processes; (d) information regarding the Company’s present and/or future products, developments, processes and systems, including invention disclosures and patent applications; (e) information on customers or potential customers, including customers’ names, sales records, prices, and other terms of sales and Company cost information; (f) Company personnel data; (g) Company business plans, marketing plans, financial data and projections; and (h) information received in confidence by the Company from third

parties. Information regarding products, services or technological innovations in development, in test marketing or being marketed or promoted in a discrete geographic region, which information the Company or one of its Affiliates is considering for broader use, shall be deemed not generally known until such broader use is actually commercially implemented.

c.

“Good Reason means, with respect to any Participant, without such Participant’s written consent, the Participant’s (i) material demotion or material diminution of duties, responsibilities and authority; (ii) material reduction in base salary or annual incentive opportunities as in effect during the 90 day period immediately prior to the Change in Control, or as the same may be increased from time to time (except for reductions in annual incentive opportunities due to individual performance adjustments); (iii) assignment to a position requiring relocation of more than fifty miles from the location of the Participant’s employment immediately prior to the Change in Control; or (iv) termination of employment by the Company or an Affiliate other than pursuant to a notice of termination which indicates the Participant’s employment has been terminated for “Cause” and sets forth in reasonable detail the facts and circumstances claimed to provide a basis for termination of Participant’s employment.

d.

“Layoff” means a layoff or redundancy in the context of a reduction in force or restructuring that is communicated as being for a period of indefinite duration and exceeding twelve months.

e.

“Leave of Absence” means an approved leave of absence from the Company or an Affiliate from which the employee has a right to return to work, as determined by the Company.

f.

“Serious Misconduct” for purposes of this Award Agreement means any misconduct identified as a ground for termination in the Company’s Code of Business Conduct, or the human resources policies, or other written policies or procedures.

g.

“Termination due to a Divestiture” for purposes of this Award Agreement means if Participant accepts employment with another company in direct connection with the sale, lease, outsourcing arrangement or any other type of asset transfer or transfer of any portion of a facility or any portion of a discrete organizational unit of the Company or an Affiliate, or if Participant remains employed by an Affiliate that is sold or whose shares are distributed to the Company stockholders in a spin-off or similar transaction (a “Divestiture”).

23.

Language. If Participant receives this Award Agreement or any other document related to the Plan translated into a language other than English and if the meaning of the translated version differs from the English version, the English version shall control.

24.

Appendix. Notwithstanding any provisions in this Award Agreement, the Units shall be subject to any special terms and conditions for Participant’s State and/or country set forth in the Appendix. Moreover, if Participant relocates to a State and/or country included in the Appendix, the special terms and conditions for such State or country shall apply to Participant, to the extent that the Company determines that the application of such terms and conditions is necessary or advisable in order to comply with local law or facilitate the administration of the Plan. The Appendix constitutes part of this Agreement.

25.

Imposition of Other Requirements. The Company reserves the right to impose other requirements on Participant’s participation in the Plan, on the Units and on any Shares acquired under the Plan, to the extent the Company determines it is necessary or advisable in order to comply with local law or facilitate the administration of the Plan, and to require Participant to sign any additional agreements or undertakings that may be necessary to accomplish the foregoing.

26.

409A Compliance Applicable Only to Participants Subject to U.S. Tax. Notwithstanding any provision in this Award Agreement to the contrary, if Participant is a “specified employee” (certain officers of the Company within the meaning of Treasury Regulation Section 1.409A-1(i) and using the identification methodology selected by the Company from time to time) on the date of Participant’s termination of employment, any payment which would be considered “nonqualified deferred compensation” within the meaning of Code Section 409A that Participant is entitled to receive upon termination of employment and which otherwise would be paid or delivered during the six month period immediately following the date of Participant’s termination of employment will instead be paid or delivered on the earlier of (i) the first day of the seventh month following the date of Participant’s termination of employment and (ii) death. For purposes of determining the time of payment or delivery of any payment Participant is entitled to receive upon termination of employment, the determination of whether Participant has experienced a termination of employment will be determined by the Company in a manner consistent with the definition of “separation from service” under the default rules of Section 409A of the Code.

27.

Acceptance of Terms and Conditions. The Company may, in its sole discretion, decide to deliver any documents related to current or future participation in the Plan by electronic means and shall notify Participant of the grant of this Award by electronic means. Participant hereby consents to receive such documents by electronic delivery and agrees to participate in the Plan through an on-line or electronic system established and maintained by the Company or a third party designated by the Company. Further, by electronically accepting this Award within 30 days after the date of the electronic mail notification by the Company to Participant of the grant of this Award (“Email Notification Date”), Participant agrees to be bound by the foregoing terms and conditions, the Plan, and any and all rules and regulations established by the Company in connection with awards issued under the Plan. If Participant does not electronically accept this Award within 30 days of the Email Notification Date, Participant will not be entitled to the Units. In the Company’s sole discretion, Participant may also be required to accept the Award in writing and to return notice of acceptance to the Company in the form prescribed by the Company within 30 days of the date that Participant is first notified of the grant of this Award.

28.

Plan Documents. You can find other information about the Units, the Plan and the Prospectus for the Plan on the Company’s website at http://my.mot-mobility.com/go/EquityAwards. If you do not have access to the website, please send your request to Equity Administration at, 6450 Sequence Drive, San Diego, CA 92121 or email: EQUITYADMIN@Motorola.com.) to request Plan documents.

Employee Signature

Printed Employee Name

Employee Commerce ID Number

Date

On behalf of Motorola Mobility Holdings, Inc.

Printed Name

Date Received

Country of Receipt