/ 2017 LSM Reimbursement
Shared LSM Funds Authorization Form
Co-op / Date

I (we) hereby authorize to use the below specified amount.

1 / Store # / Franchisee Name (Print) / Amount / 11 / Store # / Franchisee Name (Print) / Amount
2 / Store # / Franchisee Name (Print) / Amount / 12 / Store # / Franchisee Name (Print) / Amount
3 / Store # / Franchisee Name (Print) / Amount / 13 / Store # / Franchisee Name (Print) / Amount
4 / Store # / Franchisee Name (Print) / Amount / 14 / Store # / Franchisee Name (Print) / Amount
5 / Store # / Franchisee Name (Print) / Amount / 15 / Store # / Franchisee Name (Print) / Amount
6 / Store # / Franchisee Name (Print) / Amount / 16 / Store # / Franchisee Name (Print) / Amount
7 / Store # / Franchisee Name (Print) / Amount / 17 / Store # / Franchisee Name (Print) / Amount
8 / Store # / Franchisee Name (Print) / Amount / 18 / Store # / Franchisee Name (Print) / Amount
9 / Store # / Franchisee Name (Print) / Amount / 19 / Store # / Franchisee Name (Print) / Amount
10 / Store # / Franchisee Name (Print) / Amount / 20 / Store # / Franchisee Name (Print) / Amount

NOTE:This form is for authorization only and in no way withdraws money or places a “hold” on LSM funds. Franchisees will still be held responsible for managing their LSM funds.

By signing, I confirm the franchisees involved have agreed to collectively share the above listed funds.

______

Signature of Co-op President and/or Main ContactDate

For EMAILED Shared LSM Funds Authorization Forms, please e-mail to:Helene Dion ()

For MAILEDShared LSM Funds Authorization Forms,please mail to:Shared LSM Funds Authorization
Attn: Helene Dion

9311 E. Via De Ventura, Scottsdale, AZ 85258

Shared LSM Funds Authorization Form 020616© 2015-2016 Kahala Franchising, L.L.C. All rights reserved. Confidential communication for only Cold Stone Creamery® franchisees. All trademarks referenced in this communication are the property of their respective owners.