Notice Of Exemption Form - Nebraska Department Of Banking And Finance

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Nebraska Department of Banking and Finance
1230 “O” Street, Suite 400
P.O. Box 95006
Lincoln, NE 68509-5006
NOTICE OF EXEMPTION
The following seller claims an exemption from the provisions of the Nebraska Seller-
Assisted Marketing Plan Act, pursuant to Neb. Rev. Stat. § 59-1722:
1.
Name of Seller: _______________________________________________________
2.
Name under which Seller Intends to Do Business: __________________________
______________________________________________________________________
3.
Address of Seller: _____________________________________________________
______________________________________________________________________
4.
Telephone Number of Seller: ____________________________________________
5.
Description of the Business of the Franchise: _______________________________
______________________________________________________________________
The seller represents that it has complied with the disclosure requirements of either the Federal
Trade Commission trade regulation rule, 16 C.F.R. Part 436, or the uniform franchise offering
circular guidelines adopted by the North American Securities Administrators Association.
Dated __________________, 20____.
By: ________________________________
(Signature)
________________________________
(Print Signature Name)
Title: _______________________________
Filing Fee: $100.00
Make check payable to: Nebraska Department of Banking and Finance
Print Form
J:\JAF\department-forms\2006+\SB\Notice of Exemption.doc
Revised 1/2008

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