SEE BACK SIDE FOR INSTRUCTIONS FOR COUNTY CLERK-RECORDER'S USE (FBN) Statement of Withdrawal (includes registration of 1 business name, 1 or 2 registrants, and 1 certified copy)......................................................................... $37.00 Each additional business name and/or registrant (must have the same business address and registrant) on the same statement.................................................................... $7.00 STATEMENT OF WITHDRAWAL FROM PARTNERSHIP OPERATING UNDER FICTITIOUS BUSINESS NAME The following person(s) / registrant (s) has / have withdrawn as a general partner(s) from the partnership operating under the following fictitious business name(s). FORM MUST BE TYPED OR LEGIBLY COMPLETED USING BLACK INK ONLY. FICTITIOUS BUSINESS NAME ADDRESS CITY / STATE / ZIP FILED IN SANTA CLARA COUNTY ON (STREET ADDRESS OF PRINCIPAL PLACE OF BUSINESS) UNDER FILE NO. (DATE) (PREVIOUS FILE NUMBER) Please enter the full name and current address of the Registrant(s) or entity(ies) withdrawing as partner(s). NAME 1. 2. 3. ADDRESS CITY / STATE / ZIP I / WE DECLARE THAT ALL INFORMATION IN THIS STATEMENT IS TRUE AND CORRECT. (A registrant who declares as true information which he or she knows to be false is guilty of a crime) NAME 1. NAME 1. NAME 2. NAME 2. NAME 3. NAME 3. (Signed) X (Type / Print Signature) (Signed) X (Type / Print Signature) (Signed) X (Type / Print Signature) I hereby certify that this copy is a correct copy of the original STATEMENT OF WITHDRAWAL on file in my office. Regina Alcomendras, Santa Clara County Clerk-Recorder By ___________________________________________________ Deputy Dated: _________________________ CLERK-RECORDER SEAL This statement was filed with the County Clerk-Recorder of Santa Clara County on the date indicated by the filing label above. SANTA CLARA COUNTY CLERK-RECORDER'S OFFICE: www.clerkrecorder.org Rev. 2 - 4/9/2015 American LegalNet, Inc. www.FormsWorkFlow.com INFORMATION and INSTRUCTIONS FOR COMPLETING THE STATEMENT OF WITHDRAWAL FROM PARTNERSHIP OPERATING UNDER FICTITIOUS BUSINESS NAME These instructions are not required to be published (Business and Professions Code § 17924 (a)(2)). The form must be typed or legibly completed using BLACK INK only. APPLICABLE CALIFORNIA BUSINESS and PROFESSIONS CODE SECTIONS 17930 Any person who executes, files, or publishes any statement under this chapter, knowing that such statement is false, in whole or in part, shall be guilty of a misdemeanor and upon conviction thereof shall be punished by a fine not to exceed one thousand dollars ($1,000). 17923. (a) Any person who is a general partner in a partnership that is or has been regularly transacting business under a fictitious business name may, upon withdrawing as a general partner, file a statement of withdrawal from the partnership operating under a fictitious business name. The statement shall be executed by the person filing the statement in the same manner as a fictitious business name statement and shall be filed with the county clerk of the county where the partnership filed its fictitious business name statement. (b) The statement shall include: (1) The fictitious business name of the partnership. (2) The date on which the fictitious business name statement for the partnership was filed, the file number, and the county where filed. (3) The street address of its principal place of business in this state or, if it has no place of business in this state, the street address of its principal place of business outside this state, if any. (4) The full names and residence addresses of the person or persons withdrawing as partners. (c) The statement of withdrawal from the partnership operating under a fictitious business name shall be published in the same manner as the fictitious business name statement and an affidavit showing the publication of the statement shall be filed with the county clerk after the completion of the publication. (d) The withdrawal of a general partner does not cause a fictitious business name statement to expire if the withdrawing partner files a statement of withdrawal meeting the requirements of this section. 17917. (a, b) Within 30 days after a fictitious business name statement has been filed pursuant to this chapter, the registrant shall cause a statement... to be published pursuant to Section 6064 of the Government Code in a newspaper of general circulation... that circulates in the area where the business is to be conducted... in the county where the fictitious business name statement was filed... (d) An affidavit showing the publication of the statement shall be filed with the county clerk where the fictitious business name statement was filed within 30 days after the completion of the publication. Government Code § 6064. Publication of notice pursuant to this section shall be once a week for four successive weeks. FORM INSTRUCTIONS (Business and Professions Code § 17923) Fictitious Business Name - Insert all of the fictitious business names that appeared on the fictitious business name statement that is the subject of the withdrawal. The name(s) must be exactly as stated on the fictitious business name statement. Use the Addendum Page for additional business name. Address - Insert the complete, current address of the principal place of business. File Date and Number ­ Insert the file date and file number of the fictitious business name statement that is the subject of the withdrawal. This information will appear on the barcode label on the top-right corner of the statement. Full Name of Registrant(s) ­ Insert the full name and current address of each withdrawing partner. Use the Addendum Page for additional name and current address of each withdrawing partner. Signature ­ The Statement of Withdrawal from Partnership Operating Under Fictitious Business Name should be signed by the following: If the withdrawing general partner on the fictitious business name statement that is the subject of the withdrawal was: an individual - by the individual; married couple - by either one of the couple; general partnership, limited partnership, limited liability partnership, copartnership, joint venture, or unincorporated association other than a partnership - by a general partner; limited liability company - by a manager or officer; trust - by a trustee; corporation - by an officer; state or local registered domestic partnership - by one of the domestic partners American LegalNet, Inc. www.FormsWorkF