Ill. Admin. Code tit. 14 , J, Appendix C, ILLUSTRATION C
_____________ | ) | |
_____________ | ) | SS |
_____________ | ) |
IN THE MATTER OF:
FRANCHISOR:
FRANCHISEE:
BEFORE THE ATTORNEY GENERAL OF ILLINOIS
AS ADMINISTRATOR FOR THE FRANCHISE DISCLOSURE ACT
The undersigned franchisee hereby requests the Administrator to authorize release from escrow the sum of $ _______________, plus accrued interest representing the franchise fee paid by me on the ___________ day of ________________, ____.
The undersigned franchisee hereby represents that the franchisor has not fulfilled the initial obligations owed to me under the franchise and other agreements and that I have not commenced doing business.
_______________________ | |
Franchisee Signature | |
_______________________ | |
Printed Name of Franchisee | |
_______________________ | |
Address of Franchisee | |
Subscribed and sworn to before me this | _______________________ |
______ day of ______, | |
_______________________ | |
_______________________ | |
Notary Public |
Ill. Admin. Code tit. 14 , J, Appendix C, ILLUSTRATION C