TYPE OF FILING (Check one) FIRST FILING RENEWAL FILING [No Change(s) in facts from previous filing] OFFICE OF THE LAKE COUNTY CLERK Courthouse-255 N. Forbes St. Lakeport, CA 95453 (707) 263-2311 This space reserved for County Clerk FICTITIOUS BUSINESS NAME STATEMENT FILING FEE $30.00 FOR FIRST BUSINESS NAME ON STATEMENT $ 5.00 FOR EACH ADDITIONAL BUSINESS NAME FILED ON SAME STATEMENT AND DOING BUSINESS AT THE SAME LOCATION FILE #_______________________________ EXPIRATION DATE:___________________ $ 5.00 FOR EACH ADDITIONAL OWNER IN EXCESS OF TWO OWNERS The following person (persons) is (are) doing business as: *__________________________________________________________(___)_____________ Print Fictitious Business Name(s) Phone Number **__________________________________________________________________________ Street address of principal place of business Mailing address if different __________________________________________ _________________________________ City State Zip COUNTY City State Zip *** REGISTERED OWNER(S): 1. __________________________________ Full Name 2. _________________________________ Full Name __________________________________ Residence Address _________________________________ Residence Address __________________________________ City State Zip _________________________________ City State Zip __________________________________ If Corporation or LLC ­ Print State of Incorporation/Organization _________________________________ If Corporation or LLC ­ Print State of Incorporation/Organization 3. __________________________________ Full Name 4. _________________________________ Full Name __________________________________ Residence Address _________________________________ Residence Address __________________________________ City State Zip _________________________________ City State Zip __________________________________ If Corporation or LLC ­ Print State of Incorporation/Organization _________________________________ If Corporation or LLC ­ Print State of Incorporation/Organization IF MORE THAN FOUR 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 Joint Venture State or Local Registered Domestic Partners a Limited Liability Partnership a Married Couple ***** The registrant commenced to transact business under the fictitious business name or names listed above on _____________________________ (Insert N/A above if you haven't started to transact business) 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 _______________________Type or Print Name______________________________________________ If Registrant is a corporation or LLC, please print title of officer or manager authorized to sign____________________________________________________ This statement was filed with the County Clerk of LAKE COUNTY on the date indicated by the filed stamp in the upper right corner. NOTICE ­ 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). I HEREBY CERTIFY THAT THIS COPY IS A CORRECT COPY OF THE ORIGINAL STATEMENT ON FILE IN MY OFFICE. CATHY SADERLUND, LAKE COUNTY CLERK BY:_____________________________________________, Deputy American LegalNet, Inc. www.FormsWorkFlow.com CLERK: COPY CLIENT: COPY NEWSPAPER: COPY BANK: COPY 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 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 busin