STATE OF NEW YORK OFFICE OF THE ATTORNEY GENERAL Eric T. Schneiderman ATTORNEY GENERAL Franchise registration forms, statutes, regulations and guidelines can be downloaded from www.ag.ny.gov FORM G-NET WORTH EXEMPTION FORM (GBL § 684.2) ___________________________________ Franchisor _______________________________ Street Address ___________________________________ City, State Zip Code ________________________________ Telephone Number Fee: $150.00 ____________________________________ hereby submits certified copies of its most recent audited balance sheet and profit and loss statement, attached hereto and marked as Exhibit A, and hereby certifies that. 1. The franchisor, according to the statement submitted, has a net worth of not less than five million dollars or if its net worth is less than 5 million dollars and more than one million dollars, the franchisor is 80% owned by __________________, which has a net worth, on a consolidated basis, of not less than five million dollars as reflected by its most recent audited balance sheet and profit and loss statement. The identity and business experience in the detail required by Section 200.2 subdivision (c), items 2 through 4 of these regulations of persons affiliated with the franchisor is as follows: (attach rider). The franchisor will comply with the provision of Section 684.2(c) of the General Business Law. Annexed hereto as Exhibit B is applicant's completed consent to service of process form. 2. 3 4. 1 American LegalNet, Inc. www.FormsWorkFlow.com 5. This application is made for an exemption pursuant to Section 684.2 of the General Business Law. __________________________ Signature Franchisor (SEAL) By ________________________ Title _______________________ Personally appeared before me this ____day of ____________, 201__, the above named ________________, to me know to be the person who executed the foregoing application on behalf of ____________________ and, being administered an oath and duly sworn, swore upon oath that said application, and all exhibits submitted herewith, are true and correct. Notary Public ___________________ My Commission Expires ___________ 2 American LegalNet, Inc. www.FormsWorkFlow.com