Application To Amend A State Franchise {GAVFL002}

GAVFL00 2 (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 APPLICATION TO AMEND A 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 application. Pursuant to O.C.G.A. 247 36 - 76 - 5, as a m ended, the unders i gned hereby applies to amend a state franchise. 1. The na m e of the certificate holder is: 2. The franchise number of the certificate holder is : 3. Statement of Amendment(s): a. Change in Service Area: Pursuant to O.C.G.A 76 - 36 - 5 (4)(d), a cable service provider or video service provider m ay m o dify its service area covered by the st ate franc h ise by notifying the Secretary of State of changes to the service area, with a copy provi d ed to each affected m un i cipal o r co u nty gover n i n g authority, at least 20 days prior to the effective date of such change. Such notification shall contain a geographic description of the new service area or areas and a list of each m unicipal o r county go v erning a u th o rity within the ser v ice ar ea. The service are a s are described below m a . This service area change is effective on . (MM/DD/YYYY) Change in Service Area Description: American LegalNet, Inc. www.FormsWorkFlow.com GAVFL00 2 (Rev. 6/2019 ) b. Change in Principal Place of Business Address and/or Officer(s): The principal place of business of the certificate holder is: The principal exec u tive o fficer(s) of the certificate holder are: (Attach additional sheet if necessary . ) Name Title Address place of business address and/or principal executive officer(s). (Entity Name) : The new name of the certificate holder is: Submit supporting documentation showing the change of the entity name of the certificate holder with this application. An effective date is not required when 4. The certificate holder changing its service area certifies that a copy of this application has been provided to each affected municipal or county governing authority at least 20 days prior to the effective date of the change . A certificate holder changing its name, principal pla ce of business address, and/or principal executive officer(s) certifies that a copy of this application has been mailed or provided to each affected municipal or county governing authority within 7 business days following the delivery of the application to the Secretary of State. American LegalNet, Inc. www.FormsWorkFlow.com GAVFL00 2 (Rev. 6/2019 ) 5. The certificate holder agrees to co m ply will all a p plica b le federal and state laws and regulations, i n cluding municipal and county ordinances and regulations regarding the pl a cement and m aintenance of f acilities in the public right of way that are generally applicable to all use r s o f the public right of way and speci f i cally i n cluding O.C.G.A. Chapter 9 of Title 2 r gia Utility Facility Protecti o 6. The certificate holder agr e es to pay to each affect e d local gov erning authority a franchise fee esta b lished by such local governing authority which shall not exceed the m ax i m u m percenta g e rate per m itted in 47 U . S.C. Section 54 2 (b) of the ap p lica n g ro s s revenues received fr o m the provi s i on of cable service or video service to subscribers l o cated within t h e service area. Such franchise fee shall be paid directly to each affected local go v erning a u thority within 30 days after the last day of each calendar quarter . Submit ted this day of , 20. Signature of Officer/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