Filing Fee: $20.00 Office of the Secretary of State Corporations Division Trademark Section 148 W. River Street Providence, Rhode Island 02904-2615 ID No. ___________ STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS ASSIGNMENT OF A TRADEMARK OR SERVICE MARK TO BE TYPED-PLEASE READ INSTRUCTIONS BEFORE COMPLETING THIS FORM WHEREAS: 1. Name of Present Owner _________________________________________________________________________________________________ 2. (a) Principal business address ____________________________________________________________________________________________ Street _____________________________________________________________________________________________________________________ City/Town State Zip Code (b) Business address in Rhode Island, if any. (To be filled in only if principal business address is not in Rhode Island.) _____________________________________________________________________________________________________________________ Street City/Town State Zip Code 3. State whether present owner is an individual, partnership, corporation, union or association: ___________________________________________ 4. If a corporation, what is the state of incorporation? ___________________________________________________________________________ 5. Has adopted and used the ________________________________________________________________________________________________ (trademark or service mark) which is registered under No. _____________________________, as of _________________________________, _________, in the office of the Secretary of State of Rhode Island NOW, THEREFORE, to all to whom it may concern: Be it known that for good and valuable consideration, the receipt of which is hereby acknowledged, said owner has sold, assigned and transferred the registered mark, and by these presents does sell, assign and transfer unto: 6. Name of New Owner ___________________________________________________________________________________________________ 7. (a) Principal business address ____________________________________________________________________________________________ Street _____________________________________________________________________________________________________________________ City/Town State Zip Code (b) Business address in Rhode Island, if any. (To be filled in only if principal business address is not in Rhode Island.) 8. State whether present owner is an individual, partnership, corporation, union or association: ___________________________________________ 9. If a corporation, what is the state of incorporation? ____________________________________________________________________________ 10. The entire right, title and interest in and to __________________________________________________________________________________ (Indicate the mark) and the registration thereof, together with the good will of the business in connection with which the said mark is used. _____________________________________________________________ Name of Prior Owner _____________________________________________________________ Signature of Prior Owner or Authorized Representative of Prior Owner _____________________________________________________________ Title STATE OF _________________________ COUNTY OF _______________________ In __________________________________, on this _________ day of ___________________________, 20___, personally appeared before me _________________________________________________________________, who, being by me first duly sworn, declared that he/she signed the foregoing assignment in the capacity indicated and that, being informed of the contents of the assignment, he/she executed the same voluntarily. _____________________________________________________________ Notary Public My commission expires: _________________________________________ Form No. T-83 Revised: 12/05 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR FILING ASSIGNMENT OF A TRADEMARK OR SERVICE MARK Chapter 6-2 of the General Laws of Rhode Island, 1956, as amended The Assignment of a Trademark or Service Mark must be accompanied by the filing fee of $20.00. Make all money orders and checks payable to the Secretary of State. Send a separate check for each assignment. This will prevent the return of multiple assignments for correction. All blanks are to be completed before the assignment will be recorded in this office. Please return with a copy of the assignment agreement attached. An assignment of any registration under this act shall be void as against any subsequent purchaser for valuable consideration without notice, unless it is recorded with the Secretary of State within three months after the date thereof or prior to such subsequent purchase. Return to: Corporations Division Trademark Section 148 W. River Street Providence, Rhode Island 02904-2615 American LegalNet, Inc. www.FormsWorkFlow.com