LARRY W. WARD COUNTY OF RIVERSIDE ASSESSOR-COUNTY CLERK-RECORDER P.O. Box 751, Riverside, CA 92502-0751 -- (951) 486-7000 82-675 Hwy. 111, Rm. 113, Indio, CA 92201 -- (760) 863-8732 OFFICE OF THE COUNTY CLERK COUNTY CLERK'S FILING STAMP FICTITIOUS BUSINESS NAME STATEMENT SEE REVERSE SIDE FOR FEES AND INSTRUCTIONS CLERK'S USE ONLY - USE BLACK INK ONLY MUST BE TYPED OR PRINTED INITIAL CROSS OUTS NO WHITE OUT ALLOWED $____________ # _________________________ Fee Receipt Comments: ___________________________________________________ THE FOLLOWING PERSON(S) IS (ARE) DOING BUSINESS AS: 1a. Fictitious Business Name (If more than one business name at same address - Attach Supplemental Sheet) ___________________________________________________________________________________________________________________________________________________________ 1b. List COMPLETE Physical Business Address (No P.O. Boxes or Postal Facilities) 1c. Name of County (where business is located) ___________________________________________________________________________________________________________________________________________________________ Mailing Address (If different than business address – optional) ___________________________________________________________________________________________________________________________________________________________ 2a. Registrant Information (Individual, Corp., LLC, Gen. Partner, etc.) 2b. Registrant Information (Individual, Corp., LLC, Gen. Partner, etc.) ___________________________________________________________________________ ___________________________________________________________________________ If individual-spell out first, middle and last names (use dash if no middle name) If individual-spell out first, middle and last names (use dash if no middle name) ___________________________________________________________________________ ___________________________________________________________________________ Residence Address (if Corp. or LLC enter the physical address of the Corp./LCC) Residence Address (if Corp. or LLC enter the physical address of the Corp./LCC) __________________________________________________________________________ __________________________________________________________________________ City City State Zip State Zip ___________________________________________________________________________ ___________________________________________________________________________ List State of Corp./LLC. Must be registered in California 2a. Registrant Information (Individual, Corp., LLC, Gen. Partner, etc.) 2c. Registrant Information (Individual, Corp., LLC, Gen. Partner, etc.) List State of Corp./LLC. Must be registered in California 2d. Registrant Information (Individual, Corp., LLC, Gen. Partner, etc.) ___________________________________________________________________________ ___________________________________________________________________________ If individual-spell out first, middle and last names (use dash if no middle name) ___________________________________________________________________________ If individual-spell out first, middle and last names (use dash if no middle name) If individual-spell out first, middle and last names (use dash if no middle name) ___________________________________________________________________________ ___________________________________________________________________________ Residence Address (if Corp. or LLC enter the physical address of the Corp./LCC) ___________________________________________________________________________ Residence Address (if Corp. or LLC enter the physical address of the Corp./LCC) __________________________________________________________________________ __________________________________________________________________________ City State Zip Residence Address (if Corp. or LLC enter the physical address of the Corp./LCC) __________________________________________________________________________ City State Zip ___________________________________________________________________________ City ___________________________________________________________________________ ___________________________________________________________________________ List State of Corp./LLC. Must be registered in California List State of Corp./LLC. Must be registered in California List State of Corp./LLC. Must be registered in California 3. This business is conducted by: State Zip (If More Than four Registrants - Attach Additional Sheet Showing Owner Information)  Individual  Husband & Wife  Trust  Corporation  General Partnership  A Limited Partnership  Co-partners  Joint Venture  Limited Liability Company  Limited Liability Partnership  An Unincorporated Association - other than a partnership  State or Local Registered Domestic Partnership 4.  Registrant has not yet begun to transact business under the fictitious name(s) listed above.  Registrant commenced to transact business under the fictitious business name(s) listed above on ____________________________________ I declare that all the 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.) 5. Signature(s) ______________________________________________________________________________________________________ (Only one is required) Typed or Printed Name(s) ___________________________________________________________________________________________ If Limited Liability Company/Corporation, Title __________________________________________ QC’D BY: ______________________ THIS STATEMENT WAS FILED WITH THE COUNTY CLERK OF RIVERSIDE COUNTY ON DATE INDICATED BY FILE STAMP ABOVE NOTICE-IN ACCORDANCE WITH SUBDIVISION (a) OF SECTION 17920, A FICTITIOUS BUSINESS I HEREBY CERTIFY THAT THIS COPY IS A CORRECT COPY 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 THIS 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 FEDERAL, STATE OR COMMON LAW (SEE SECTION 14411 ET SEQ., BUSINESS AND PROFESSIONAL CODE). ACR 500 (Rev. 1/2012) Available in Alternate Formats OF THE ORIGINAL STATEMENT ON FILE IN MY OFFICE. LARRY W. WARD RIVERSIDE COUNTY CLERK By___________________________________, Deputy American LegalNet, Inc. www.FormsWorkFlow.com NOTICE TO REGISTRANT PURSUANT TO SECTION 17924 BUSINESS & PROFESSIONS CODE (1) Your fictitious business name statement must be published in a newspaper within 30 days after the statement has been filed with the County Clerk. The statement must be published once a week for four consecutive weeks and an affidavit of publication filed with the County Clerk within 30 days after publication has been completed. The statement shall be published in a newspaper of general circulation in the County where the principal place of business is located. The statement should be published in a newspaper that circulates in the area where the business is to be conducted. (Section 17917, B&PC) For renewal of 5-year expiration: If any change has occurred in the facts in your original statement, your new statement must be published as required above. If no changes have occurred, and a new filing is filed within 40 days of expiration of the previous statement, publication is not required. The determination whether or not publication is required is ENTIRELY the responsibility of the registrant. (Section 17917(c) B&PC) (2) 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.) (Section 17930 B&PC) FEES Fictitious Business Name Statement - $35.00 for one business name and one registrant plus $7.00 for each additional business at the same address; $7.00 for each additional registrant. Conformed copies - 50¢ a page; Certified copies - $3.00; Search for Business/Registrant name - $5.00 per name; INSTRUCTIONS FOR COMPLETION OF STATEMENT (17913 & 17914 B&PC) Document must be legibly typed or printed in black ink. No copies will be returned unless a stamped, self-addressed envelope is provided. 1a. Insert the fictitious business name(s). Only those businesses operated at the same address may be listed on one statement. 1b. If the registrant has a place of business in this state, specify the street address of his/her place of business in this state. If the registrant has no place of business in this state, the Fictitious Business Name Statement shall be filed with the County Clerk of Sacramento County – (section 17915, B&PC). The name of the city and county for the business and registrant(s) address, must be spelled out completely. Mail box or Post Office Box numbers, when used alone, are not acceptable. 2a. If the registrant is an individual, insert his or her full name (first, middle and last) and residence address. If the registrant is a partnership or other association of persons, insert the full name (first, middle and last) and residence address of each general partner. If the registrant is a business trust, insert the full name (first, middle and last) and residence address of each trustee, including the name of the trust, (i.e. Mary Smith, Trustee of the Smith Family Trust) Mail box or Post Office Box numbers, when used alone, are not acceptable. If the registrant is a corporation or a limited liability company, insert the name and address of the corporation / limited liability company as set out in its articles of incorporation / organization, and the state of incorporation / organization. 3. Indicate which of the terms best describes the nature of the business. (i.e. co-partners, individual, corporation, etc.) 4. Indicate in appropriate box whether or not the business is open, and if open, give date business opened. 5. If the registrant is an individual, the statement must be signed by the individual. If registrant is a partnership or other association of persons, the statement must be signed by a general partner. If the registrant is a limited liability company, the statement must be signed by a manager or officer. If the registrant is a business trust, the statement must be signed by a trustee. If the registrant is a corporation, the statement must be signed by an officer. EXPIRATION OF STATEMENT Notice – Except as provided in Section 17923 of the Business & Professions Code, the statement expires 40 days after any change in the facts set forth in the statement. However, a mere change in the residence address of an individual, general partner or trustee does not cause the statement to expire prior to the end of the five year term. The Statement expires upon the filing of a Statement of Abandonment. The Statement does not expire if a withdrawing partner files and publishes a Statement of Withdrawal and all other facts remain as originally filed. LEGAL ADVICE and/or ASSISTANCE Neither the County Clerk nor his deputies are permitted by law to give legal advice and/or assistance. The registrant should either consult the Business and Professions Code, which is available at the County Law Library, and may be available at City and/or County Libraries, or seek professional legal assistance. American LegalNet, Inc. www.FormsWorkFlow.com ACR 500 (Rev. 1/2012) Available in Alternate Formats