FOR OFFICIAL USE ONLY Agent Owner TYPE OF IDENTIFICATION PROVIDED: DRIVER222S LICENSE MILITARY ID ACK P ASSPORT OTHER EXPIRATION DATE: TYPE OF FILING (Check one) New Filing [Change(s) in facts from previous filing]Refile [No Change(s) in facts from previous filing] Previous file # OFFICE OF THE CALAVERAS COUNTY CLERK 891 Mountain Ranch Road San Andreas, CA 95249 FICTITIOUS BUSINESS NAME STATEMENT FILING FEE $.00 FOR FIRST BUSINESS NAME ON STATEMENT $ 5.00 FOR EACH ADDITIONAL BUSINESS NAME FILED ON SAME STATEMENT AND DOING BUSINESS AT THE SAME L LOCATION $ 5.00 FOR EACH ADDITIONAL OWNER IN EXCESS OF ONE O W OWNER This space reserved for County Clerk The following person (persons) is (are) doing business as: *Print Fictitious Business Name(s)**|Street address of principal place of business Mailing address if different | City State Zip COUNTY City State Zip *** REGISTERED OWNER(S): 1. 2. Full Name- First Middle Last Full Name- First Middle LastResidence Address/Mailing AddressResidence Address/Mailing AddressCity State Zip City StateZipIf Corporation or LLC 226 Print State of Incorporation/Organization If Corporation or LLC 226 Print State of Incorporation/Organization 3. 4. Full Name- First Middle Last Full Name- First Middle LastResidence Address/Mailing AddressResidence Address/Mailing AddressCity State Zip City StateZipIf Corporation or LLC 226 Print State of Incorporation/Organization If Corporation or LLC 226 Print State of Incorporation/Organization IF MORE THAN FOUR REGISTRANTS, ATTACH ADDITIONAL SHEET SHOWING OWNER INFORMATION **** THIS BUSINESS IS CONDUCTED BY: (Check one) an Individuala General Partnershipa Limited Partnershipa Limited Liability Company an Unincorporated Association other than a Partnershipa Corporationa TrustCopartnersa Married CoupleJoint VentureState or Local Registered Domestic Partnersa Limited Liability Partnership ***** The registrant commenced to transact business under the fictitious business name or names listed above on (Insert N/A above if you haven222t started to transact business) 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).) SIGNATURE OF REGISTRANT Print full name of person signing. If corporation, also print corporate title of officer. If LLC, also print title of officer or manager. This statement was filed with the County Clerk of CALAVERAS COUNTY on the date indicated by the filed stamp in the upper right corner. NOTICE 226 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. 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). IF SUBMTTING THE STATEMENT IN PERSON, THE REGISTRANT OF AGENT WILL BE ASKED TO PRESENT A VALID PHOTO I.D. FOR ALL THE FICTITIOUS BUSINESS NAME FILINGS. I HEREBY CERTIFY THAT THIS COPY IS A CORRECT COPY OF THE ORIGINAL STATEMENT ON FILE IN MY OFFICE. BY:, Deputy REBECCA TURNER, COUNTY CLERK-RECORDER Rev. American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR COMPLETION OF STATEMENT Business and Professions Code Section 17913: * Where one asterisk appears in the form: (a) Insert the 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 of business outside this state and file with the Clerk of Sacramento County (B&P 17915) (c) Mail Box and Post Office Box Numbers are not acceptable as a business address 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 a married couple insert the full name and residence address of both of parties to the marriage (c) If the registrant is a 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 (d) If the registrant is a limited partnership, insert the full name and residence address 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 CA 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 CA 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) Check whichever of the terms listed on the front of the form 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) Insert N/A if you have not yet commenced to transact business under the fictitious business name or names listed Business and Professions Code Section 17914 The statement shall be signed as follows: (a) If the registrant is an individual, the statement shall be signed by an individual. (b) If the registrants are a married couple, the statement shall be signed by either party to the marriage. (c) If the registrant is a general partnership, limited liability partnership, co-partnership, joint venture, or unincorporated association other than a partnership, the statement shall be signed by a general partner. (d) If the registrant is a limited partnership, the statement shall be signed by the general partner listed in the registrant field, the title 223general partner224 shall be entered on the line for title. (e) If the registrant is a limited liability company, the statement shall be signed by a manager or officer as listed in their articles of organization. State title of the person signing. (f) If the registrant is a trust, the statement shall be signed by a trustee. State title of the person signing. (g) If the registrant is a corporation, the statement shall be signed by an officer. State the title of the officer. (h) If the registrant is a state or local registered domestic partnership, the statement shall be signed by one of the domestic partners. A FICTITIOUS BUSINESS NAME STATEMENT GENERALLY EXPIRES AT THE END OF THE FIVE (5) YEARS FROM THE DATE IT WAS FILED IN THE OFFICE OF THE COUNTY CLERK, except, as provided in Section 17920(b) of the Business and Professions Code, where it expires forty days after any change in the facts set forth in the statement. However, a change in the residence of an individual, general partner, or trustee does not cause the statement to expire until the end of the five-year term. THE STATEMENT EXPIRES UPON THE FILING AND PUBLICATION OF A STATEMENT O