Notice Of Transfer Of State Franchise {GAVFL003}

GAVFL003 (Rev. 6 /2019 ) Secretary of State OFFICE OF SECRETARY OF STATE CORPOR A TIONS DIVISION 313 West Tower 2 Martin Luther King Jr. Dr. Atlanta, GA 30334 (404) 656 - 2817 sos.georgia.gov/corporations NOTICE OF TRANSFER OF STATE FRANCHISE Personally appeared be f ore m e the undersigned being duly sworn accor d ing to law, and swears to the facts contained in this notice . Pursuant to O.C.G.A. 247 36 - 76 - 5 , as a m ended, the unders i gned hereby provides notice of the transfer of a state franchise to provide cable service and/or video service in the State of Georgia from the current certificate holder to a successor in interest (the . 1. The na m e of the certificate holder is: 2. F ranchise number of the certificate holder is: 3. Date of issue of certificate of state franchise : 4. The name of the transferee to whom the state franchise is being transferred : 5. The principal place of busi n ess of t h e transferee is: 6 . The mailing address of the transferee is: 7. The principal exec u tive o fficer(s) of the transferee are: (Attach additional sheet if necessary . ) Name Title Address American LegalNet, Inc. www.FormsWorkFlow.com Page 2 GAVFL00 3 (Rev. 6 /2019 ) 8. governing authority within the service area , is described below and/or on the attached m : Service Area Description: 9 . initial application for a state franchise. (Attach additional sheet if necessary . ) 10. Pursuant to O.C.G.A 36 - 76 - 5(a) , t he transferee certifies that this notice has been filed with the Secretary of State with a copy provided to each affected municipal or county governing authority within 45 days of the transfer . 11. Transferee acknowledges that any outstanding liabilities that have become due and are still owed to a municipal or county governing authority under a state franchise issued to the certificate holder shall be fully transferable to any successor in interest to the certificate holder. 1 2 . The transferee agrees to co m ply will all a p plica b le federal and state laws and regulations, i n cluding municipal and county ordinances and regulations regarding the pl a cement and m aintenance of f acilities in the public right of way that are generally applicable to all use r s o f the public right of way and speci f i cally i n cluding O.C.G.A. Chapter 9 of Title 2 5, the American LegalNet, Inc. www.FormsWorkFlow.com Page 3 GAVFL00 3 (Rev. 6 /2019 ) r gia Utility Facility Protecti o n Act . 1 3 . The a p plica n t agr e es to pay to each affect e d local governing authority a franchise fee esta b lished by such local governing authority which shall not exceed the m ax i m u m percenta g e rate per m itted in 47 U . S.C. Section 54 2 (b) of the ap p lica n g ro s s revenues received fr o m the provi s i on of cable service or video service to subscribers l o cated within t h e service area. Such franchise fee shall be paid directly to each affected local go v erning a u thority within 30 days after the last day of each calendar quarter. Submit ted this day of , 20 . Signature of Officer/General Partner Print Name Title Address Telephone Number Email Address State of County of Sworn to and subscribed before m e this day of , 20. Notary Public Signature My Com m ission expires : American LegalNet, Inc. www.FormsWorkFlow.com