FILING FEE $46.00 For first business name on statement $ 2.00 For each additional business name filed on same statement and doing business at the same location $ 2.00 For each additional owner in excess of one owner 1. BE SURE TO READ INSTRUCTIONS ON REVERSE 2. SEND ORIGINAL and 3 COPIES TO MENDOCINO COUNTY CLERK, 501 Low Gap Rd., Room 1020, Ukiah, CA 95482. We will keep the original and return the copies (one certified) after filing. (Please include a stamped, self-addressed envelope.) COUNTY CLERK'S FILING STAMP FICTITIOUS BUSINESS NAME STATEMENT The following person(s) is (are) doing business as: Fictitious Business Name(s) Street Address, City, State & Zip of Principal Place of Business in California Mailing Address (If different) Full Name of Registrant Full Name of Registrant Residence Address Residence Address City State Zip City State Zip (If Corporation or Limited Liability Company, show state of incorporation) (If Corporation or Limited Liability Company, show state of incorporation) Full Name of Registrant Full Name of Registrant Residence Address Residence Address City State Zip City State Zip (If Corporation or Limited Liability Company, show state of incorporation) (If Corporation or Limited Liability Company, show state of incorporation) (If More Than 4 Registrants -- Attach Additional Sheet Showing Owner Information) This business is conducted by: an Individual a Corporation Copartners an Unincorporated Association - other than a Partnership Married Couple a General Partnership a Trust Joint Venture State or Local Registered Domestic Partners a Limited Partnership a Limited Liability Company a 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 any material matter pursuant to Section 17913(a) of the Business & 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 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 Mendocino County on date indicated by file stamp above. 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. SUSAN M. RANOCHAK COUNTY CLERK BY ______________________________________________________ DEPUTY File No. _________________________________________ NEW RENEWAL REVISED 1/1/2014 American LegalNet, Inc. www.FormsWorkFlow.com WHITE TO COUNTY CLERK; YELLOW TO CUSTOMER; PINK TO BANK; GOLDENROD TO NEWSPAPER INSTRUCTIONS FOR COMPLETION OF STATEMENT Business and Professions Code Section 17913: FICTITIOUS BUSINESS NAME: (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 ADDRESS: (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 FULL NAME OF REGISTRANT: (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 (c) If the registrant is a general partnership, co-partnership, 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 THIS BUSINESS IS CONDUCTED BY: (a) Check whichever of the terms listed on the front of the form best describes the nature of the business THE REGISTRANT COMMENCED TO TRANSACT BUSINESS UNER THE FICTITIOUS BUSINESS NAME OR NAMES LISTED ABOVE: (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, by the individual (b) If the registrants are husband and wife, by t