Modification Of Boundaries Of Video Service Provider

Arkansas Secretary of State Mark Martin 501-682-3409 · www.sos.arkansas.gov 1401 W. Capitol, Suite 250, Little Rock, AR 72201 MODIFICATION OF BOUNDARIES OF VIDEO SERVICE PROVIDER 1. Video Service Provider: 2. Date Certificate of Franchise Authority Was Issued by Secretary of State: 3. Please identify below, political subdivisions and/or parts of political subdivisions which have been added or removed from the service area in which the franchise holder provides video service. If the service area includes an entire county, please list all political subdivisions within the county. Added Counties: (please indicate if the video service area is the entire county or a portion of the county. If the service area includes only a portion of the county, please describe the area.) Removed Counties: (please indicate if the video service area is the entire county or a portion of the county. If the service area includes only a portion of the county, please describe the area.) Added Cities/Towns: (please identify all cities/towns within the service area. If the service area includes only a portion of a city or town, please describe the area) Removed Cities/Towns: (please identify all cities/towns within the service area. If the service area includes only a portion of a city or town, please describe the area) 4. Date Franchise Holder intends to begin providing video service for modified areas listed above: AFFIDAVIT I, the undersigned, being first duly sworn, state that I am an officer, general partner, or managing member of the Video Service Provider listed above, that I have read the above document and know its contents and that the facts stated therein are true and correct: Signature Printed Name State of Arkansas County of On this the day of , 20 , before me, Title Date , the undersigned notary, personally appeared known to me (satisfactorily proven) to be the person whose name is subscribed to the within instrument and acknowledged that he/she executed the same for the purposes therein contained. In witness whereof I hereunto set my hand and official seal. Notary Public: [Notary Seal] My Commission Expires: Filing Fee $100.00, payable to Arkansas Secretary of State American LegalNet, Inc. www.FormsWorkFlow.com Rev. 07/15