FORM TM0 5 (Rev. 6/2019 ) OFFICE OF SECRETARY OF STATE CORPORATIONS DIVISION 2 Martin Luther King Jr. Dr. SE Suite 313 West Tower Atlanta, Georgia 30334 (404) 656 - 2817 http://sos.ga.gov/ Secretary of State VOLUNTARY CANCELLATION OF REGISTRATION TRADEMARK OR SERVICE MARK P URSUANT TO O.C.G.A. 24710 - 1 - 448, THE UNDERSIGNED HER EBY APPLIES TO THE S ECRETARY OF S TATE TO VOLUNTARILY CANCEL THE FOLLOWING TRADEMARK OR SERVICE MARK REGISTRATION : 1. R EGISTRATION N UMBER : 2. N AME OF M ARK : 3. D ATE OF R EGISTRATION : 4. N AME OF R EGISTRANT : A DDRESS OF R EGISTRANT : 5. I CERTIFY , UNDER THE PENALTY O F PERJURY , THAT I AM AUTHORIZED TO SI GN THIS APPLICATION , AND THAT THE ABOVE STATEMENTS A RE TRUE AND CORRECT . T HE MARK REGISTRATION IS VOLUNTARILY CANC ELLED UPON THE FILIN G OF THIS REQUEST . S IGNATURE OF R EGISTRANT : D ATE : P RINT OR T YPE N AME : T ITLE ( IF SIGNING FOR AN EN TITY ): E MAIL : Mail or deliver to the Secretary of State, at the above address, the following: ( 1) This completed application; and ( 2) Filing fee of $15.00 payable to the Secretary of State. Fees are non - refundable and non - transferable . F ILING F EE : $ 15.00 American LegalNet, Inc. www.FormsWorkFlow.com