275-321A [Rev. 09/18] MELISSA WILK, Alameda County Clerk-Recorder 1106 Madison Street, Oakland, CA 94607 Telephone: (510) 272-6362 Website: www.acgov.org STATEMENT OF ABANDONMENT OF USE OF FICTITIOUS BUSINESS NAME TYPE OR PRINT LEGIBLY AND FIRMLY IN BLACK OR DARK BLUE INK ONLY *Original File Number: A. **THE PERSON(S) LISTED BELOW HAVE ABANDONED THE USE OF THE FOLLOWING FICTITIOUS BUSINESS NAME(S): (Please Print or Type) T h e F ict i ti o u s Bu si n e ss N a m e Statement filed on in the County of Alameda. FBN Filed Date F i c ti t i o u s B u s in e ss N a m e (s) ( as filed) A d dr e s s o f P r i n c ip a l pl ac e o f b u s i n e s s (as filed) C ity S t a te Z ip C o u n t y B. *** REGISTERED OWNER(S): (If more than four owners, attach Additional Information Form showing owner information) C. ****THIS BUSINESS IS CONDUCTED BY: (Check one) an Individual Married Couple State or local registered Domestic Partners Co-partners a Joint Venture a General Partnership a Limited Liability Partnership a Trust a Corporation a Limited Partnership a Limited Liability Company an Unincorporated association other than a partnership I declare that all information in this statement is true and correct. A registrant who declares as true any material matter pursuant to this section that the registrant knows to be false is guilty of a misdemeanor punishable by a fine not to exceed one thousand dollars ($1,000). Registrant (Print name) Title (If Corporation, print title of officer. If LLC, print title of officer or manager.) D. *****Registrant Signature (See instructions for authorized signatories/titles) This statement was filed with the Clerk-Recorder of Alameda County on the date indicated by the filing stamp in the upper right hand corner. White - Copy Yellow Copy - Bank & other Required Needs (Certified) Pink Copy - Newspaper Copy Goldenrod Copy - 1. Registrant /Corp/LLC Residence Address (P.O. Box not accepted) C it y S t a t e Z i p If Corporation or LLC Print State of Incorporation/Organization 2. Registrant /Corp/LLC Residence Address (P.O. Box not accepted) C it y S t a t e Z i p If Corporation or LLC Print State of Incorporation/Organization 4. Registrant /Corp/LLC Residence Address (P.O. Box not accepted) C it y S t a t e Z i p If Corporation or LLC Print State of Incorporation/Organization 3. Registrant /Corp/LLC Residence Address (P.O. Box not accepted) C it y S t a t e Z i p If Corporation or LLC Print State of Incorporation/Organization American LegalNet, Inc. www.FormsWorkFlow.com 275-321A [Rev. 09/18] INSTRUCTIONS FOR COMPLETION OF STATEMENT THE INFORMATION BELOW IS NOT TO BE PUBLISHED (SEC. 17924, B&P) REQUIREMENTS FOR STATEMENT OF ABANDONMENT OF USE OF FICTITIOUS BUSINESS NAME (Sec. 17922 B&P Code) A person who has filed a fictitious business name statement shall, upon ceasing to transact business in the state under that fictitious business name, file a statement of abandonment of use of fictitious business name. The abandonment shall be executed in the same manner as a fictitious business name statement and shall be filed with the county clerk of the county in which the person has filed his fictitious business name statement. The abandonment shall be published in the same manner as a fictitious business name statement and an affidavit showing its publication shall be filed with the county clerk after the completion of publication. INSTRUCTIONS FOR COMPLETING THE STATEMENT (Sec. 17922 B&P Code). Type or print legibly and firmly in black or blue ink only. * Insert the original File Number of previous filed Fictitious Business Name. A. ** Insert the date on which the fictitious business name statement relating to the name being abandoned, previously filed. Insert the fictitious business name(s) being abandoned. The name(s) must be exact name(s) as shown on the fictitious business name statement. More than one business name may be listed on the abandonment form ONLY if all the names were originally listed on the same FBN statement form. If more than one name is listed, number each name; the Additional Information form may be used to list additional names. Insert the street address of the principal place of business as previously filed. (P.O. Box, postal drop box, mailing suite, or c/o addresses are not acceptable.) B. *** List each registrant and residence address separately as filed; include all registrants that appeared on the original statement other than partners who have previously withdrawn from the partnership. (P.O. Box, postal drop box, mailing suite, and c/o addresses are not acceptable.) C. **** Business conducted by: Check whichever of the terms listed on the front of the form which best describes the nature of the business being abandoned. D. ***** At least one of the registrants must sign. Signature of registrant must be executed in same manner as the FBN statement. NOTICE TO REGISTRANT (Sec. 17924 B&P Code) Within 30 days after the statement of abandonment has been filed with the county clerk, the statement must be published in a newspaper of general circulation in the county where the principal place of business was located. The newspaper selected should be one that circulates in the area where the business was conducted. The statement must be published once a week or four successive weeks with five days between each date of publication. An affidavit of publication must be filed with the county clerk within 30 days after the completion of the publication. (Sec. 17917 B&P Code, Sec. 6064 Gov. Code) Any person who executes, files, or publishes any fictitious business name statement, knowing that such statement is false, in whole or in part, is guilty of a misdemeanor and upon conviction thereof shall be fined not to exceed one thousand dollars ($1000). (Sec. 17930 B&P Code) American LegalNet, Inc. www.FormsWorkFlow.com