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Form 3005--General Information (Notice of Escrow Account)
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 Health Spas are governed by Chapter 702 of the Texas Occupations Code (the "Health Spa Act") and the secretary of state's administrative rules found in 1 Texas Administrative Code Chapter 102. If an escrow deposit is required by Section 702.352 of the Health Spa Act, the following items must be filed with the secretary of state not later than the 14th day after the date the first prepayment is accepted: 1. A notarized statement identifying the financial institution holding the escrow account and the name in which the escrow account is held; and 2. A signed statement on a form approved by the secretary of state authorizing the secretary of state to direct inquiries to the financial institution regarding the escrow account. This form is designed to fulfill both requirements.
Exemptions to the escrow deposit requirement may be found in Section 702.353 of the Health Spa Act.
Instructions for Form Identifying Information: Include the health spa certificate holder's name and address, the location of the health spa, the name and address of the financial institution at which the escrow deposit was made, the name in which the escrow account is held, and the escrow account number. Authorization: The Health Spa Act requires this statement to be filed with the secretary of state not later than the 14th day after the date the first prepayment is accepted. Execution: A person who is authorized to sign on behalf of the health spa must sign and date the notice before a notary public or other official who has authority to administer an oath. Delivery Instructions: The form may be mailed to P.O. Box 13550, Austin, Texas 78711-3550 or delivered to the James Earl Rudder Office Building, 1019 Brazos, Austin, Texas 78701.
Revised 03/09

Form 3005

1

Form #3005

Rev. 03/2009

This space reserved for office use

Submit to: SECRETARY OF STATE Statutory Documents Section P O Box 13550 Austin, TX 78711-3550 512-463-6906 512-475-2815 Fax Filing Fee: None

NOTICE OF ESCROW ACCOUNT

Identifying Information
Name of health spa certificate holder: Address of health spa certificate holder:
Street City State Zip

Location of health spa (if different from certificate holder's address):
Street City State Zip

Name of Financial Institution: Address of Financial Institution:
Street City State Zip

Name in which escrow account is held: Account Number:

Authorization
The secretary of state is authorized to direct inquiries to the financial institution regarding the escrow account identified above.

Execution
Date:
Signature of authorized person

State of County of

) )

Printed or typed name of authorized person

Sworn to and subscribed before me this (seal)

day of
Notary Public Signature

, 20

.

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