DEMAND FOR ARBITRATION

Please provide the following information in connection with your dispute with CouponInsanity (“Responding Party”), as submitted by you or the organization that you represent (“Initiating Party” and together with the Responding Party, the “Parties”):

Name of the Initiating Party:                   ____________________________________
Address of the Initiating Party:               ____________________________________
                                                ________________________________________
                                                ________________________________________
Telephone Number of Initiating Party:     ____________________________________
E-mail Address of Initiating Party:                      ____________________________________

Name of Responding Party:                               CouponInsanity
Address of Responding Party:                           24 W. Railroad Ave., #139
                                                Tenafly, NJ 07670

                                                                        

E-mail Address of Responding Party:                info@CouponInsanity.com

The Initiating Party previously agreed to the CouponInsanity .com Terms and Conditions (“Terms”).  The Terms contain a valid and binding arbitration clause for the resolution of disputes, a copy of which is attached hereto as Exhibit A.  The Parties are in dispute as to the following issue(s):
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

As the Parties cannot agree as to the resolution of the subject dispute, the Initiating Party hereby demands that the Responding Party submit to arbitration pursuant to the rules and procedures set forth by either the American Arbitration Association (“AAA”) or the Judicial Arbitration and Mediation Services, Inc. (“JAMS”), as selected by the Initiating Party.

The Initiating Party is claiming the following damages:

__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
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Total Damages Claimed $ ___________________

In filing this Demand for Arbitration (“Demand”), the Initiating Party certifies the following:

He/she/it has provided the Responding Party with a copy of this Demand by both e-mail and by certified mail, return receipt requested.

So demanded and certified, this _____ day of ________________, 20__.

            ___________________________________________________
Initiating Party

Sworn to and subscribed before me, this _____ day of __________________, 20__.

            ___________________________________________________
Notary Public.

(PLEASE NOTE:  Notarization is required for original and mailed copies only.  Notarization is not required to file or serve this Demand via e-mail)