SEE REVERSE SIDE FOR INSTRUCTIONS CHARLES LOMELI SOLANO COUNTY CLERK 675 Texas Street, Suite 1900 Fairfield, California 94533-6337 (707) 784-7510 This Space for Use of County Clerk FICTITIOUS BUSINESS NAME STATEMENT $50.00 FOR FIRST BUSINESS NAME ON STATEMENT 7.00 FOR EACH ADDITIONAL BUSINESS NAME FILED ON SAME STATEMENT AND DOING BUSINESS AT THE SAME LOCATION 7.00 FOR EACH ADDITIONAL OWNER IN EXCESS FILING FEES ARE TO BE PAID BY CASH OF ONE OWNER CASHIER'S CHECK MONEY ORDER OR DEBIT CARD THE FOLLOWING PERSON (PERSONS) IS (ARE) DOING BUSINESS AS: FILING FEE * ** LOCATED AT: (Print Fictitious Business Name(s) on Line Above) Street Address of Business (City) (City) (State) (State) (Telephone Number) (Zip) (Zip) (County) (County) Mailing address if different *** #1 ___________________________________________ (Full Name ­ Type/Print) IS (ARE) HEREBY REGISTERED BY THE FOLLOWING OWNER(S): #3 ___________________________________________ (Full Name ­ Type/Print) ___________________________________________ ___________________________________________ (City and Zip) Residence Address or State of Incorporation/Organization-if incorporated or LLC ___________________________________________ ___________________________________________ (City and Zip) Residence Address or State of Incorporation/Organization-if incorporated or LLC #2 ___________________________________________ (Full Name ­ Type/Print) #4 __________________________________________ (Full Name ­ Type/Print) ___________________________________________ ___________________________________________ (City and Zip) Residence Address or State of Incorporation/Organization-if incorporated or LLC ___________________________________________ Residence Address or State of Incorporation/Organization-if incorporated or LLC ___________________________________________ (City and Zip) **** (If More Than 4 Registrants ­ Attach Additional Sheet Showing Owner Information) THIS BUSINESS IS CONDUCTED BY: (Check one) an Individual a General Partnership a Limited Partnership a Limited Liability Company an Unincorporated Association other than a Partnership a Corporation a Trust Copartners A Married Couple Joint Venture State or Local Registered Domestic Partners Limited Liability Partnership *****The registrant commenced to transact business under the fictitious business name or names listed above on _______ I 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.) SIGNATURE OF REGISTRANT: Print Name of Person Signing. If corporation, also print corporate title of officer. If LLC, also print title of officer or manager. IN ACCORDANCE WITH SUBDIVISION (a) OF SECTION 17920 A FICTITIOUS NAME STATEMENT GENERALLY EXPIRES AT THE END OF FIVE YEARS FROM THE DATE ON WHICH IT WAS FILED IN THE OFFICE OF THE COUNTY CLERK, EXCEPT AS PROVIDED IN SUBDIVISION (b) OF SECTION 17920, WHERE IT EXPIRES 40 DAYS AFTER ANY CHANGE IN THE FACTS SET FORTH IN THE STATEMENT PURSUANT TO SECTION 17913 OTHER THAN A CHANGE IN THE RESIDENCE ADDRESS OF A REGISTERED OWNER. A NEW FICTITIOUS BUSINESS NAME STATEMENT MUST BE FILED BEFORE THE EXPIRATION ______________________20_________. THE FILING OF THIS STATEMENT DOES NOT OF ITSELF AUTHORIZE THE USE IN THIS STATE OF A FICTITIOUS BUSINESS NAME IN VIOLATION OF THE RIGHTS OF ANOTHER UNDER FEDERAL, STATE OR COMMON LAW (SEE SECTION 14411 ET SEQ., BUSINESS AND PROFESSIONS CODE). . _______ NEW _______ RENEWAL ASSIGNED FILE NO. I hereby certify that this copy is a correct copy of the original statement on file in my office. CHARLES LOMELI, SOLANO COUNTY CLERK Deputy American LegalNet, Inc. www.FormsWorkFlow.com By INSTRUCTIONS FOR COMPLETION OF STATEMENT * ** Business and Professions Code Section 17913 Where one asterisk appears in the form: (a) Insert fictitious business name or names. (b) Only those businesses operated at the same address and under the same ownership may be listed on one statement. Where two asterisks appear in the form: (a) If the registrant has a place of business in this State, insert the street address and County of his or her principal place of business in this state. (b) If the registrant has no place of business in this State, insert the street address and County of his or her principal place outside this State and file with the Clerk of Sacramento County. (c) Mail Box and Post Office Box Numbers are not acceptable as business addresses, when used alone, without a street address. Where three asterisks appear in the form: (a) If the registrant is an individual, insert his or her full name and residence address. (b) If the registrants are husband and wife, insert full name and residence address of both the husband and wife. (c) If the registrant is a general partnership, copartners, joint venture, limited liability partnership or unincorporated association other than a partnership, insert the full name and residence address of each general partner. (Attach additional sheets if necessary) (d) If the registrant is a limited partnership, insert the full name and residence of each general partner. (e) If the registrant is a limited liability company, insert the name and address of the limited liability company, as set out in its articles of organization on file with the California Secretary of State, and the state of organization. (f) If the registrant is a trust, insert the full name and residence address of each trustee. (g) If the registrant is a corporation, insert the name and address of the corporation, as set out in its articles of incorporation on file with the California Secretary of State, and the state of incorporation. (h) If the registrants are state or local registered domestic partners, insert the full name and residence address of each domestic partner. Where four asterisks appear in the form: (a) Indicate which of the terms best describes the nature of the business. Where five asterisks appear in the form: (a) Insert the date on which the registrant first commenced to transact business under the fictitious business name or names listed, if already transacting business under that name or names. (b) If the registrant has not yet commenced to transact business under the fictitious business name or names listed, insert the statement, "Not applicable". Business and Professions Code Section 17914 The statement shall be signed as follows: (a) If the registrant is an individual, by the individual (b) If the reg