State of North Carolina DEPARTMENT OF THE SECRETARY OF STATE Counterfeit Trademark/Service Mark ComplaintThe purpose of this form is to provide information to the North Carolina Department of the Secretary of State foruse in the investigation of claims of counterfeit trademarks and service marks made pursuant to N.C.Gen. Stat. 80-11.1. Please provide detailed responses to the following questions.1. Name, address and telephone number of individual/organization completing this form: ________________________________________________________________________ ________________________________________________________________________2. Name, address and telephone number of individual/organization against whom these allegations are made: ________________________________________________________________________ ________________________________________________________________________3. State whether the trademark or service mark allegedly counterfeited is registered on the principal register of the United States Patent and Trademark Office, including the owner of the mark, date of registration and registration number: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________4. State whether the trademark or service mark allegedly counterfeited is registered with the Trademark Division of the Department of the Secretary of State of North Carolina, including the owner of the mark, date of registration and registration number: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________5. State whether the mark allegedly counterfeited is protected by Section 110 of the Amateur Sports Act of 1978 (Title 36, U.S.C. 380): ________________________________________________________________________ ________________________________________________________________________6. Accurately describe the trademark or service mark which has allegedly been counterfeited (in the alternative, you may attach a copy of the state or federal registration): ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________7. Describe with specificity the manner in which the above-referenced trademark or service mark has been counterfeited. Include within this response the estimated retail sales value of the goods or services having a counterfeit mark used thereon or in connection therewith. (Attach additional pages if necessary). ________________________________________________________________________ ________________________________________________________________________>>>> 2 ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________8. Identify the name, address and phone number of any witness(es) to the alleged counterfeiting of the trademark or service mark, or any individual(s) who have knowledge of the use, possession, manufacture or sale of the counterfeit mark as described herein: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________9. State whether any federal, state, county, municipal or other law enforcement agencies have been advised of the counterfeit activity alleged in this complaint. If so, identify the name of the agency, the individual to whom information was given and their address and phone number: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________10. State whether you have in your possession samples of the counterfeit mark as used on or in connection with goods or services and, if so, whether such samples may be made available for inspection by this agency. Include a brief description of the sample. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________11. State the location where goods or services having a counterfeit mark used thereon or in connection therewith may be obtained: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________12. If this complaint involves an object, tool, machine or other device used to produce or reproduce a counterfeit mark, state the name of the individual who has custody of the device and the address where said device may be found: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________Date of Complaint: ____________________ Signature of Signature ofComplainant: __________________________ Complainant: _________________________