Form 3004--General Information (Health Spa Assignment of Certificate of Deposit) The attached form is designed to meet minimal statutory filing requirements pursuant to the relevant code provisions. This form and the information provided are not substitutes for the advice and services of an attorney. Commentary According to Chapter 702 of the Texas Occupations Code (the "Health Spa Act"), the secretary of state may not issue a health spa operator's certificate of registration unless proof of security or exemption is filed with the application for registration. This form is designed for applicants electing to satisfy the security requirement by assigning a certificate of deposit to the secretary of state. The required amount of security is determined by reference to the following table: Total amount paid for prepaid memberships at health spa location $0�$20,000 $20,001�$25,000 $25,001�$30,000 $30,001�$35,000 $35,001�$40,000 $40,001�$45,000 Over $45,000 Amount of Security $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 Instructions for Form � � Assignor: Provide the name and address of the person who was issued the certificate of deposit. Health Spa: Provide the name of the health spa applying for the certificate of registration. The name of the health spa must match the name on the application for certificate of registration. The assignor and the health spa are typically the same entity. Certificate of Deposit: Provide the number used by the financial institution to identify the certificate of deposit and the amount of the certificate of deposit in both words and numbers. Financial Institution: Provide the name and mailing address of the financial institution or credit union that issued the certificate of deposit. The issuing financial institution or credit union must be either: (1) a financial institution in Texas whose deposits are insured by the Federal Deposit Insurance Corporation or the Savings Association Insurance Fund; or (2) a credit union insured by the National Credit Union Administration. Agreement & Understanding of the Parties: A person who is authorized to sign on behalf of Assignor must sign and date the assignment. Acknowledgement by Financial Institution: Before the assignment form is submitted to the secretary of state, a person authorized to sign on behalf of the issuing financial institution or credit union must sign and date the assignment. Receipt for Security & Directions to Pay Earnings: Leave this section blank. Upon filing, the secretary of state will execute this section authorizing the issuing financial institution or credit union to pay any earnings on the certificate of deposit to the Assignor and send a copy of the filed Assignment of Certificate of Deposit to the financial institution or credit union. Delivery Instructions: A copy of the document issued by the union that evidences the existence of the certificate of deposit executed assignment form. The documents may be mailed to 13193, Austin, Texas 78711-3193 or delivered to the James Earl Brazos, 1st Floor, Austin, Texas 78701. Revised 12/2014 � � � � � financial institution or credit must be filed along with the Registrations Unit, P.O. Box Rudder Office Building, 1019 American LegalNet, Inc. www.FormsWorkFlow.com Form 3004 1 Form #3004 Rev. 12/2014 This space reserved for office use Submit to: SECRETARY OF STATE Registrations Unit P O Box 13193 Austin, TX 78711-3193 512-475-0775 512-475-2815 - Fax Filing Fee: None. ASSIGNOR Name: HEALTH SPA ASSIGNMENT OF CERTIFICATE OF DEPOSIT Mailing Address HEALTH SPA Name: Location CERTIFICATE OF DEPOSIT FINANCIAL INSTITUTION Number: Amount: Name: Mailing Address City State Zip City State Payee: The State of Texas Zip City State Zip AGREEMENT & UNDERSTANDING OF THE PARTIES In order to obtain a certificate of registration for the health spa specified and for the purpose of providing security for financial loss due to the cessation of operation of the health spa identified, the ASSIGNOR specified, for the benefit of the state and each member of the health spa who suffers financial loss due to the health spa's cessation of operation, in the name of the health spa, assigns and sets over irrevocably to the secretary of state any and all right, title, claim and interest of whatever nature of ASSIGNOR in and to the CERTIFICATE OF DEPOSIT ("CD") described above. For the purpose of this assignment, "financial loss" shall be determined under the Health Spa Act, Texas Occupations Code, Chapter 702. ASSIGNOR agrees that this assignment carries with it the right to any insurance on the CD that may now or in the future exist and includes and gives to the secretary of state the exclusive right to redeem, collect and withdraw at any time any part of or the full amount of the CD to be applied as a payment to the state or to any member of the health spa identified who suffers financial loss due to the health spa's cessation of operation. (The right of the secretary of state to apply the CD shall not be affected by a subsequent change in the trade name or business location of the person or entity on whose behalf this assignment is executed.) ASSIGNOR understands and agrees that by this assignment all right, title and claim to interest in, use of and control over the disposition of the CD is relinquished and that such CD is to be held by the financial institution identified to the sole use and subject to the exclusive control of the secretary of state. This CD may be released only by the secretary of state's written direction. This is notification by the ASSIGNOR to the financial institution of the terms of this assignment. Date: Signature of authorized person for ASSIGNOR Printed or typed name of authorized person for ASSIGNOR ACKNOWLEDGEMENT BY FINANCIAL INSTITUTION The FINANCIAL INSTITUTION acknowledges the assignment of this CERTIFICATE OF DEPOSIT ("CD") to the secretary of state. We certify that we have recorded the assignment and have retained a copy. We certify that we do not have, nor do we have knowledge of, anyone else having any lien, encumbrance, Form 3004 2 American LegalNet, Inc. www.FormsWorkFlow.com right, hold, claim to or obligation of the CD. We accept the CD with knowledge that it has been irrevocably posted for and on behalf of the state and each member of the health spa who suffers financial loss due to the health spa's cessation of operation and we agree to act as the sole agent for the purpose of holding this security for the secretary of s