THIS STATEMENT IS A PUBLIC RECORD FICTITIOUS BUSINESS NAME STATEMENT COUNTY OF TEHAMA - OFFICE OF THE COUNTY CLERK 633 WASHINGTON ST., RM 11 P.O BOX 250 RED BLUFF, CA 96080 (530) 527-3350 FILING FEE: $31.00 for one business name, includes one registrant/owner name. $5.00 for each additional registrant/owner or additional business name. SEE REVERSE SIDE FOR INSTRUCTIONS. 1) This filing is a: First filing (Publication Required) Refile of previous file # With Changes (Publication Required) (check appropriate box(es) below) Refiled prior to expiration or within 40 days past expiration, with NO CHANGES After 40 days of expiration date (Publication Required) Due to publication requirement not met on previous filing (Publication Required) Mailed ID Verified THE FOLLOWING PERSON(S) IS (ARE) DOING BUSINESS AS: NOTICE: This statement expires five years from the date it was filed in the office of the County Clerk. A new FBN statement must be filed no more than 40 days from expiration. This filing does not of itself authorize the use of this name in violation of the rights of another under federal, state or common law. (B & P Code 14411 et seq.) 2) Fictitious Business Name(s) A: Phone Number: B: 3) Street Address of Principal Place of Business (P.O. Box not acceptable) Business Mailing Address if different from above Name of Registrant (Person, Corporation or LLC name) City State: Zip Code: Corp or LLC show Registration State 4) Last: Residence Address and P.O. Box Business Mailing Address if different from above Name of Registrant (Person, Corporation or LLC name) First: City: State: Articles of Incorporation #: Corp or LLC show Registration State Zip Code: State: 5) Last: Residence Address and P.O. Box Business Mailing Address if different from above First: City: State: Articles of Incorporation #: Zip Code: State: 6) The registrant commenced to transact business under the fictitious business name or names listed above on (Date): not applicable 7) a limited partnership* an unincorporated association a general partnership other than a partnership limited liability partnership* limited liability company* state or local registered domestic partners (An asterisk (*) item requires proof of registration with the California Secretary of State's Office) CHECK ONLY ONE This business is conducted by: an individual married couple co-partners joint venture a corporation* a trust I declare that all information in this statement is true and correct. (A registrant who declares as true any material matter pursuant to Section 17913 of the Business and Professions Code that the registrant knows to be false is guilty of a misdemeanor punishable by a fine not to exceed one thousand dollars ($1,000).) 8) IF REGISTRANT IS NOT A CORPORATION SIGN BELOW 9) CORPORATIONS AND LLCS, ONLY (Provide Articles of Incorporation) Signature Signature Signature Type or Print Name Type or Print Name Type or Print Name Corporation or Company Name Signature of Officer and Title Type or Print Name IF SUBMITTING THE STATEMENT IN PERSON, THE REGISTRANT OR AGENT WILL BE REQUIRED TO PRESENT VALID PHOTO ID FOR ALL THE FICTITIOUS BUSINESS NAME FILINGS. FOR OFFICE USE ONLY CERTIFICATION: I hereby certify that the foregoing is a correct copy of the original on file in my office. BEVERLY ROSS, County Clerk and Recorder By: ___________________________________________, Deputy American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR COMPLETION -FORM MUST BE LEGIBLY COMPLETED USING BLACK INK ONLY 1. FILING STATUS: Please check the appropriate box. If this filing is a REFILE or RENEWAL, insert the Previous File Number and check the applicable box(es). NOTE: This office will always send information addressed to the business name and address identified in section #2 and #3. 2. FICTITIOUS BUSINESS NAME(S): Insert the exact NAME OF THE BUSINESS. Please use an addendum page if you are registering more than 1 business names. All business names on the same filing must have the same business address and owner. If the BUSINESS NAME includes the words CORPORATION, CORP., INC., LIMITED LIABILITY COMPANY, LIMITED LIABILITY PARTNERSHIP, LIMITED PARTNERSHIP or any abbreviation indicating such business entity, i.e., LLC, LLP, or LP., the ownership entity identified in section #4 must also be the same business entity type. 3. ADDRESS OF BUSINESS: Insert the street address of the principal place of business in California, including the county. DO NOT USE P.O. BOX, RENTAL DROP BOXES, PMB'S, C/O (IN CARE OF) ADDRESSES. If the registrant has no place of business in California, the proper place to file the Fictitious Business Name Statement is with the Clerk-Recorder's Office of Sacramento County. 4-5. OWNER/REGISTRANT NAME(S) AND ADDRESS: Insert SEPARATELY (one name per section) the name and address of each registrant-owner as identified below. Do NOT use P.O.Box, rental mail/drop box, PMB or ? addresses. If the registrant is: an individual insert his or her full name and residence address; married couple -insert the full name and residence address of both parties to the marriage; general partnership, copartnership, joint venture, limited liability partnership, or unincorporated association other than a partnership insert the full name and residence address of each general partner; limited partnership -insert the full name and residence address of each general partner; 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; trust -insert the full name and residence address of each trustee; corporation insert the name and address of the corporation, as identified in its articles of incorporation on file with the California Secretary of State; state or local registered domestic partners -insert the full name and residence address of each domestic partner. 6. DATE OF COMMENCEMENT OF BUSINESS: If you have already started to transact business under the fictitious business name being registered, enter the date started. Check the second box if you have not yet begun. 7. TYPE OF BUSINESS OWNERSHIP: Check the box which best describes the business organization/type that is conducting the business. NOTE: Corporations, Limited Liability Companies, Limited Liability Partnerships and Limited Partnerships require proof of registration with the California Secretary of State's Office. 8-9. SIGNATURES: The statement shall be signed as follows: If the