Form 3004
1
Form 3004—General Information
(Health Spa Assignment of Certificate of Deposit)
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
According to Chapter 702 of the Texas Occupations Code (the “Health Spa Act”), the secretary of state
may not issue a health spa operator’s certificate of registration unless proof of security or exemption is
filed with the application for registration. This form is designed for applicants electing to satisfy the
security requirement by assigning a certificate of deposit to the secretary of state.
The required amount of security is determined by reference to the following table:
Total amount paid for prepaid memberships at health spa location Amount of Security
$0–$20,000 $20,000
$20,001–$25,000 $25,000
$25,001–$30,000 $30,000
$30,001–$35,000 $35,000
$35,001–$40,000 $40,000
$40,001–$45,000 $45,000
Over $45,000 $50,000
Instructions for Form
• Assignor: Provide the name and address of the person who was issued the certificate of deposit.
• Health Spa: Provide the name of the health spa applying for the certificate of registration. The
name of the health spa must match the name on the application for certificate of registration.
The assignor and the health spa are typically the same entity.
• Certificate of Deposit: Provide the number used by the financial institution to identify the
certificate of deposit and the amount of the certificate of deposit in both words and numbers.
• Financial Institution: Provide the name and mailing address of the financial institution or credit
union that issued the certificate of deposit. The issuing financial institution or credit union must
be either: (1) a financial institution in Texas whose deposits are insured by the Federal Deposit
Insurance Corporation or the Savings Association Insurance Fund; or (2) a credit union insured
by the National Credit Union Administration.
• Agreement & Understanding of the Parties: A person who is authorized to sign on behalf of
Assignor must sign and date the assignment.
• Acknowledgement by Financial Institution: Before the assignment form is submitted to the
secretary of state, a person authorized to sign on behalf of the issuing financial institution or
credit union must sign and date the assignment.
• Receipt for Security & Directions to Pay Earnings: Leave this section blank. Upon filing, the
secretary of state will execute this section authorizing the issuing financial institution or credit
union to pay any earnings on the certificate of deposit to the Assignor and send a copy of the
filed Assignment of Certificate of Deposit to the financial institution or credit union.
Delivery Instructions: A copy of the document issued by the financial institution or credit
union that evidences the existence of the certificate of deposit must be filed along with the
executed assignment form. The documents may be mailed to Registrations Unit, P.O. Box
13193, Austin, Texas 78711-3193 or delivered to the James Earl Rudder Office Building, 1019
st
Brazos, 1 Floor, Austin, Texas 78701.
Revised 12/2014
