(1) FILE # The fictitious business Name was filed in CALAVERAS COUNTY on: insert date filed OFFICE OF THE CALAVERAS COUNTY CLERK 891 Mountain Ranch Road San Andreas, CA 95249 STATEMENT OF ABANDONMENT OF USE OF FICTITIOUS BUSINESS NAME FILING FEE $25.00 Each additional certified copy is $2.25 This space reserved for County Clerk (2) Name of Business: Street address of principal place of business: (3) REGISTERED OWNER(S) Withdrawing: 1. 2. Full Name Full Name Residence Address Residence Address City State Zip City State Zip If Corporation or LLC 226 Print State of Incorporation/Organization If Corporation or LLC 226 Print State of Incorporation/Organization 3. 4. Full Name Full Name Residence Address Residence Address City State Zip City State Zip If Corporation or LLC 226 Print State of Incorporation/Organization If Corporation or LLC 226 Print State of Incorporation/Organization (4) 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 a Limited Liability Partnership I declare that all information in this statement is true and correct. (A registrant who declares as true as true any material 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).) (5) 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. This statement was filed with the County Clerk of CALAVERAS COUNTY on the date indicated by the file stamp in the upper right corner. I HEREBY CERTIFY THAT THIS COPY IS A CORRECT COPY OF THE ORIGINAL STATEMENT ON FILE IN MY OFFICE. REBECCA TURNER, COUNTY CLERK-RECORDER BY:, Deputy Rev. 9/21/2017 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR COMPLETION OF STATEMENT OF ABANDONMENT Business and Professions Code 17923 Section 17922 Business & Professions Code: Upon ceasing to transact business in this state under a fictitious business name that was filed in the previous five years, a registrant who has filed a fictitious business name statement shall file a statement of abandonment of use of fictitious business name. The statement of 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 registrant has filed fictitious business name statement. The statement 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. The statement shall include: (1) Where (1) appears in the form on the front side: The date on which the fictitious business name statement relating to the fictitious business name being abandoned was filed, the file number, and The county where filed. (2) Where (2) appears in the form on the front side: The name being abandoned and the street address of the principal place of business. (3) Where (3) appears in the form on the front side: If the registrant is an individual, insert his or her full name and residence address. If the registrants are a married couple, insert the full name and residence address of both parties to the marriage. If the registrant is a general partnership, limited partnership, copartners, a limited liability partnership, a joint venture, or an unincorporated association other than a partnership, insert the full name and residence address of each general partner. If the registrant is a corporation, insert the name and address of the corporation, as set forth in its articles of incorporation on file with the CA Secretary of State, and the state of organization. If the registrant is a trust, insert the full name and residence address of each trustees. If the registrant is a limited liability company, insert the name and address of the limited liability company, as set forth in its articles of organization on file with the CA Secretary of State, and the state of organization. If the registrants are state or local registered domestic partners, insert the full name and residence address of each domestic partner. (4) Where (4) appears in the form on the front side: Mark the appropriate box that indicates who the business is conducted by. (5) Where (5) appears in the form on the front side: If the registrant is an individual, the statement shall be signed by an individual. If the registrant(s) is a married couple, the statement shall be signed by either one of the parties. If the registrant is a general partnership, limited partnership, limited liability partnership, co-partnership, joint venture, or unincorporated association other than a partnership, the statement shall be signed by a general partner. If the registrant is a limited liability company, the statement shall be signed by a manager or officer. If the registrant is a trust, the statement shall be signed by a trustee. If the registrant is a corporation, the statement shall be signed by an officer. If the registrant is a state or local registered domestic partnership, the statement shall be signed by one of the domestic partners. Section 17923 Business & Professions Code 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 in accordance with Section 17923 Business & Professions Code. INSTRUCTIONS ON NEWSPAPER PUBLICATION REQUIREMENTS Section 17924 Business & Professions Code Your statement of abandonment of use of fictitious business name must be published in a newspaper once a week for four successive weeks and an affidavit of publication filed with the county clerk when publication has been accomplished. The statement shall be published in a newspaper of general circulation in the county where the principal place of business is located, or if no such newspaper in that county, in a newspaper of general circulation in an adjoining county. (Business and Professions Code Section 17917). Certified Newspapers of General Circulation in Calaveras County: Calaveras Enterprise The Valley Springs News 15 North Main Street The Terrace P. O. Box 1197 1906 Vista Del Lago Drive Suite L San Andreas CA 95249 Valley Springs CA209-772-2234 95252 209-754-3861 209-772-2234 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 ($1,000) (Business and Professions Code Section 17930). American LegalNet, Inc. www.FormsWorkFlow.com