Notice Of Termination Of State Franchise {GAVFL004}

GAVFL00 4 (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 TERMINATION 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(e), as a m ended, the unders i gned hereby provides notice of termination of a state franchise to provide cable service and/or video service in the State of Georgia. 1. The na m e of the certificate holder is: 2. Franchise number of the certificate holder is: 3. The following service area(s) are affected by this termination: (Attach additional sheet if necessary . ) 4. The effective date for this termination of service, which shall not be more than 60 days from the date of filing the notice of termination, is . 5. The certificate holder certifies that a copy of this notice of termination has been provided to each affected municipal or county governing a uthority. Submit ted this day of , 20 . Signature of Of ficer/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