Exemption For Franchisor To Existing Franchisee Pursuant To GBL 684(3)(D) {Form H}

STATE OF NEW YORK OFFICE OF THE ATTORNEY GENERAL ERIC T. SCHNEIDERMAN ATTORNEY GENERAL Franchise registration forms, statutes, regulations and guidelines can be downloaded from www.ag.ny.gov FORM H­EXEMPTION FORM FOR FRANCHISOR TO AN EXISTING FRANCHISEE PURSUANT TO GBL § 684(3)(D) Fee: $150.00 The Report shall contain the following information: 1. 2. 3. 4. 5. 6. State of County of Name, address and telephone number of franchisor. Name, address and telephone number of franchisee. The date from which the franchisee has actively operated its franchise. The address and telephone number of the franchise to be acquired. The price of the franchise sold. A statement by the purchasing franchisee that it is purchasing the franchise in order to operate the business and not for the purpose of resale. ) )ss. ) _________________________ being duly sworn, deposes and says that he/she has read this report and knows the contents thereof and that the same is true to his/her own knowledge. _________________________________ Name of Franchisor (SEAL) By ______________________________ Title _____________________________ Sworn to before me this day of 20 ____________________ NOTARY PUBLIC 1 American LegalNet, Inc. www.FormsWorkflow.com