STATE OF NORTH CAROLINA DEPARTMENT OF THE SECRETARY OF STATE AFFIDAVIT OF USE OF A MARK UNDER N.C.G.S. §80-5 MARK: REGISTRATION NO: REGISTRATION DATE: CLASS NO.: ………………………………………………… (Name of Person signing the Affidavit, and official capacity) being hereby warned that willful false statements, and the like, may jeopardize the validity of this document, and that failure to submit this document pursuant to N.C.G.S. §80-5 shall be grounds for cancellation of the registration of the mark by the Secretary o State, declares that ……………….. ………………………….. f (Registrant of the mark) owns the above identified registration issued, as shown by records filed in this office; that the mark shown therein is still in use in connection with the goods and/or services recited in the registration, {(with the exception of ……………………………………………………..... ............................................................................................................................................................) (list those goods or services which have been dropped, if applicable)}, as evidenced by the specimen(s) attached showing the mark as currently used in the class of goods and/or servi ces in which the mark is registered, and that all statements made of registrant’s own knowledge are true and all statements made on information and belief are believed to be true. REGISTRANT ……………………………………………. BY ……………………………………………. TITLE ……………………………………………. DATE ……………………………………………. North Carolina _______________________ County I, _____________________________, a Notary Public for __________________ County, North Carolina, do hereby certify that _______________________________ personally appeared before me this day and acknowledged the due execution of the foregoing instrument. Witness my hand and official seal, this the _____ day of _____________, 20 ____. (Official Seal) Notary Public My commission expires _____________________, 20 ___. Month and Day American LegalNet, Inc. www.USCourtForms.com