Affidavit Of Use Of A Mark

STATE OF NORTH CAROLINA DEPARTMENT OF THE SECRETARY OF STATE AFFIDAVIT OF USE OF A MARK UNDER N.C.G.S. 80-5 MARK: REGISTRATION NO: REGISTRATION DATE: CLASS NO.: (Name of Person signing the Affidavit, and official capacity) being hereby warned that willful false statements, and the like, may jeopardize the validity of thisdocument, and that failure to submit this document pursuant to N.C.G.S. 80-5 shall be grounds forcancellation of the registration of the mark by the Secretary of State, declares that .... (Registrant of the mark) owns the above identified registration issued, as shownby records filed in this office; that the mark shown therein is still in use in connection with the goodsand/or services recited in the registration, {(with the exception of ..... ..................................................................................................................................................................)(list those goods or services which have been dropped, if applicable)}, as evidenced by thespecimen(s) attached showing the mark as currently used in the class of goods and/or services inwhich the mark is registered, and that all statements made of registrants own knowledge are true and allstatements made on information and belief are believed to be true. REGISTRANT . BY . TITLE . DATE . STATE OF COUNTY OF Before me . , a Notary Public, personally appeared. who being duly sworn, declared that he signed the foregoing applicationin the capacity indicated and that the statements contained therein are true. This the day of 19___. . Notary Public My commission expires: .