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Stephen M. Feidelman, P.A.

2134 Hollywood Blvd.

Hollywood, Florida 33020

Broward: 954-927-2889

Miami-Dade: 305-931-4100

Fax: 954-923-6545

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Contact Information

First Name:	*
Last Name:	*
Email Address:	*
Phone Number:	*
Full Mailing Address:

Briefly Tell Us the Nature of Your Problem

Details:

Franchise Information

Name of Franchise System:
State of residence:
State where unit is/was located :
How many units do you own:
Names of all partners:
Date of franchise agreement signing:
Did you sign a state specific franchise agreement amendment/rider?	Yes No
Did you sign a negotiated franchise agreement amendment/rider?	Yes No

Corporate and Financial Information

Who (you or your company ["S Corp.", Partnership or LLC]) paid for each of the following and whether, if you paid, it was trated as a loan to your company:

Amount of initial franchise fee paid:
Amount of franchisor required equipment:
Amount each of fixtures, furnishings, office equipment and supplies, if any:
Amount of opening inventory:
Amount of leasehold build-out costs:
Terms of lease and any lease addendum or special terms required by franchisor:
Did you sign a promissory note in favor of the franchisor or any of its affiliates?	Yes No
Have all royalties due franchisor been paid to date?	Yes No
Have all advertising fees due to franchisor or ad fund been paid to date?	Yes No
Have all promissory note payments been paid to date?	Yes No
Are any payments made by EFT?	Yes No
If yes, are any made from a 3rd party billing service?	Yes No
If yes, are any made directly from your bank account?	Yes No

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