ASSIGNMENT OF TRADEMARK / SERVICE MARK State Form 48258 (R4 / 4-12) Approved by State Board of Accounts, 2006 CONNIE LAWSON SECRETARY OF STATE TRADEMARKS DIVISION 302 W. Washington St., Rm. E018 Indianapolis, IN 46204 Telephone: (317) 232-6540 FILING FEE: $ 10.00 INSTRUCTIONS: 1. A nonrefundable check or money order in the amount of $10.00, made to the order of Secretary of State of Indiana, must accompany this completed application. 2. A separate application, including a $10.00 fee, must be filed for each Mark filed. 3. Please type or print. 4. Mail application and fee to address listed in the upper right corner of this form. TRADEMARK / SERVICE MARK DESCRIPTION / ASSIGNMENT HISTORY Name and / or brief description of Mark to be assigned: Indiana Secretary of State file number: Date of registration (month, day, year) INFORMATION ABOUT THE ASSIGNOR (Current owner of Mark) INFORMATION ABOUT THE ASSIGNOR (Current owner of Mark) Name Address (number and street, city, state, and ZIP code) Telephone number ( ) INFORMATION ABOUT THE ASSIGNEE (Party to acquire Mark) Name Address (number and street, city, state, and ZIP code) If corporation, state of domicile INFORMATION ABOUT THE CONTACT PERSON (If correspondence about this application should go to a party other than the Assignee) Name Address (number and street, city, state, and ZIP code) Telephone number ( DE JURE ASSIGNMENT ) WHEREAS, Assignor has adopted and has continuously used the above identified Mark which is registered in the office of the Secretary of State of Indiana; and WHEREAS, Assignee is desirous of acquiring said Mark and registration thereof. NOW THEREFORE, for good and valuable consideration, receipt of which is hereby acknowledged, the Assignor does hereby assign unto the Assignee all rights, title and interest in and to the said Mark, together with that part of the good will of the business represented by the Mark and the registration thereof. VERIFICATION STATEMENT I, ____________________________________________________, affirm under penalty of perjury that I am (check box that applies) the individual owner, a partner, or an officer (title) ________________________________ of the Assignor and that, I have read this application and its contents are true and complete to the best of my knowledge. Signature Date (month, day, year) American LegalNet, Inc. www.FormsWorkFlow.com