Termination Of Certificate Of Franchise Authority For Video Service Provider

TERMINATION OF CERTIFICATE OF FRANCHISE AUTHORITY FOR VIDEO SERVICE PROVIDER 1 . Video Service Provider: 2. Date Certifi cate of Franchise Authority Was I ssued by Secretary of State: 3. Date of Termination: 4 . Please identify below , the political subdivisions and /or parts of political subdivisions to whom the Video Service provider has given written notice of termination. AFFIDAVIT I, the undersigned, being first duly sworn, state that I am an officer, general partner, or managing member of the Video Service Provider listed above, that I have read the above document and know its contents and that the facts stated therein are true a nd correct: Signature Title State of Arkansas Printed Name Date County of On this the day of , 20 , before me, , the undersigned notary, personally appeared known to me (satisfactorily proven) to be the person whose name is subscribed to the within instrument and acknowledged that he/she executed the same for the purposes therein contained. In witne ss whereof I hereunto set my hand and official seal. [Notary Seal] Notary Public: My Commission Expires: Counties : (please indicate if the video service area is the entire county or a portion of the county. If the service area includes only a portion of the county, please describe the area.) Cities/Towns: (please identify all cities/towns within the service area If the service area includes only a portion of a city or town, please describe the area.) Rev. Filing Fee $100.00, payable to Arkansas Secretary of State 001027021n024030n030007r013027r031n027035025016007031n031r$'#$t 003n026020031025022037004020031031022r006025013021 American LegalNet, Inc. www.FormsWorkFlow.com