Sample Item 23: Receipts

ITEM 23: RECEIPTS

Receipt

This disclosure document summarizes certain provisions of the franchise agreement and other
information in plain English. Read this disclosure document and all agreements carefully.

If Belmont offers you a franchise, it must provide this disclosure document to you 14 calendar
days before you sign a binding agreement with, or make a payment to, the franchisor or an affiliate in
connection with the proposed franchise sale.

If Belmont does not deliver this disclosure document on time or if it contains a false or misleading
statement, or a material omission, a violation of federal law and state law may have occurred and should
be reported to the Federal Trade Commission, W ashington, D.C. 20580 and [state agency].

Belmont’s sales agent for this offering is Roger Owens, 111 Capitol Street, Indianapolis, IN (123-
555-5555).

Issuance date: April 15, 2008

I received a disclosure document dated April 15, 2008, that included the following Exhibits:

A. Belmont Franchise Agreement
B. Belmont Lease of Premises
C. USA Credit Corp. Equipment Lease
D. Belmont Equipment Purchase Note
E. Belmont Initial Fee Loan Agreement
F. Belmont Operating Manual Table of Contents
G. Belmont Confidentiality and Noncompete Agreement for Outlet Managers
H. Belmont Noncompete Agreement for Franchisee Shareholders
I. Belmont Guarantee of Performance for Franchisee Shareholders
J. Belmont Mufflers Audited Financial Statements for 2005, 2006, and 2007
K. Richard McDonald Audited Financial Statements for 2005, 2006, and 2007
L. CTF International Audited Financial Statements for 2005, 2006, and 2007
M. CTF International Guarantee of Performance

Date:_____________ Your name (Please print): _________________________________________
Your signature:__________________________________________________

You should return one copy of the signed receipt either by signing, dating, and mailing it to Belmont at
111 First Street, Jackson, MN 55000, or by faxing a copy of the signed receipt to Belmont at (111) 223-
3344. You may keep the second copy for your records.