Affidavit Of Compliance-Franchise Amendment Renewal {E}

FORM E Rev. 7/99 COMMONWEALTH OF VIRGINIA STATE CORPORATION COMMISSION Division of Securities and Retail Franchising Affidavit of Compliance -- Franchise Amendment/Renewal STATE OF ____________________) )ss; COUNTY OF __________________) ___________________, being duly sworn, deposes and says: 1. This affidavit is submitted in connection with an application to amend/r enew the effective franchise registration of ____________________________________________ in accordan ce with 21 VAC 5-110- 40 or 21 VAC 5-110-50. (Name of Franchisor/Subfranchisor) 2. To the best of my knowledge, the franchisor/subfranchisor on whose behalf the application to amend/renew is made: a. Has not, since the effective date of its most recent application, been c onvicted of any crime or been held liable in a civil action by final judgment involving a felony, an a ct of fraud, a misdemeanor involving a franchise, or a knowing or willful violation of the Virginia Retail Franchising Act; and b. Is not insolvent or in danger of becoming insolvent, either in the sense that its liabilities exceed its assets (determined in accordance with Generally Accepted Accounting Pri nciples) or in the sense that it cannot meet its obligations as they mature. 3. The revised franchise disclosure document submitted in connection with the application to amend/renew is, to the best of my knowledge, in compliance with the requirements of 21 VAC 5-110-80 and 21 VAC 5- 110-90. Executed at ___________________________, _______________________________ _____. _____________________________________________ Name of Franchisor/Subfranchisor By: ___________________________________(SEAL) Title: __________________________________ Select Amendment Effective Date Select Renewal Effective Date ____ Immediately Upon Request ______ Immediately Upon Receipt ____ _______________ ____ ______ ________________ ____ Note: When a renewal application includes amendments, a selection shoul d be made for both the amendments and the renewal. If no selection is made, the effectiveness will be immediately upon receipt by the Commission. Subscribed and sworn to before me, a Notary Public, this _______ day of __________, ___. __________________ My Commission Expires: _________________ (NOTARYS S EAL) (NOTARY PUBLIC) American LegalNet, Inc. www.USCourtForms.com