Nebraska Department of Banking and Finance 1230 “O” Street, Suite 400 P.O. Box 95006 Lincoln, NE 68509-5006 NOTICE OF EXEMPTION The following seller claims an exemption from the provisions of the Nebraska SellerAssisted Marketing Plan Act, pursuant to Neb. Rev. Stat. § 59-1722: 1. Name of Seller: _______________________________________________________ 2. Name under which Seller Intends to Do Business: __________________________ ______________________________________________________________________ 3. Address of Seller: _____________________________________________________ ______________________________________________________________________ 4. Telephone Number of Seller: ____________________________________________ 5. Description of the Business of the Franchise: _______________________________ ______________________________________________________________________ The seller represents that it has complied with the disclosure requirements of either the Federal Trade Commission trade regulation rule, 16 C.F.R. Part 436, or the uniform franchise offering circular guidelines adopted by the North American Securities Administrators Association. Dated __________________, 20____. By: ________________________________ (Signature) ________________________________ (Print Signature Name) Title: _______________________________ Filing Fee: $100.00 Make check payable to: Nebraska Department of Banking and Finance Revised 1/2008 American LegalNet, Inc. www.FormsWorkflow.com