BARBARA K. CEGAVSKE Secretary of State 202 North Carson Street Carson City, Nevada 89701-4201 (775) 684-5708 Website: www.nvsos.gov Application for Amendment to Certificate of Authority (PURSUANT TO NRS CHAPTER 711) Page 1 USE BLACK INK ONLY - DO NOT HIGHLIGHT ABOVE SPACE IS FOR OFFICE USE ONLY 1. Name of Certificate Holder: 2. Following is a description of each new service area designated to provide video service: (mark box to confirm) Attached is an 8 1/2" x 11" map of each such service area that shows the territorial boundaries of each local government located, in whole or in part, within the new service area. Nevada Secretary of State CA Amend Page 1 Revised: 1-5-15 American LegalNet, Inc. www.FormsWorkFlow.com BARBARA K. CEGAVSKE Secretary of State 202 North Carson Street Carson City, Nevada 89701-4201 (775) 684-5708 Website: www.nvsos.gov Application for Amendment to Certificate of Authority (PURSUANT TO NRS CHAPTER 711) Page 2 USE BLACK INK ONLY - DO NOT HIGHLIGHT ABOVE SPACE IS FOR OFFICE USE ONLY 3. The required processing fee for this filing is calculated as follows: $1000.00 Application Fee + Certificate Fee = Total Required Processing Fee Certificate Fee: Based upon the information that has been set forth in section 2 of this application form the certificate fee for the Amended Certificate of Authority is: (a) $250.00 - Service area located entirely within the territorial boundaries of a town, township or city whose population is less than 1,000, regardless of the population of the county. (b) $2,500.00 - Service area located entirely within the territorial boundaries of a town, township or city whose population is 1,000 or more but less than 50,000, regardless of the population of the county. (c) $2,500.00 - Service area located entirely within the territorial boundaries of a county whose population is less than 50,000, unless the provisions of 3(a) or 3(b) apply. (d) $15,000.00 - Service area located in whole or in part within the territorial boundaries of a county whose population is 50,000 or more but less than 100,000, unless the provisions of 3(a), 3(b) or 3(e) apply. (e) $25,000.00 - Service area located in whole or in part within the territorial boundaries of a county whose population is 100,000 or more unless the provisions of 3(a) or 3(b) apply. or $0.00 - Applicant holds Certificate of Authority that permits, but does not require, applicant to provide video service within one or more service areas located anywhere in this state as designated in this application and affidavit and has paid the one-time $25,000.00 certificate fee. 4. Signature of Certificate Holder: Name Title X Authorized Signature American LegalNet, Inc. www.FormsWorkFlow.com Nevada Secretary of State CA Amend Page 1 Revised: 1-5-15