COUNTY OF RIVERSIDE ASSESSOR-COUNTY CLERK-RECORDER P.O. Box 751, Riverside, CA 92502-0751 -- (951) 486-7000 OFFICE OF THE COUNTY CLERK COUNTY CLERK'S FILING STAMP FICTITIOUS BUSINESS NAME STATEMENT SEE REVERSE SIDE FOR FEES AND INSTRUCTIONS -USE BLACK INK ONLY -MUST BE TYPED OR PRINTEDINITIAL CROSS OUTSNO WHITE OUT ALLOWED THE FOLLOWING PERSON(S) IS (ARE) DOING BUSINESS AS : CLERK'S USE ONLY $ # Fee Receipt Comments: 1a. Fic titious 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 226 optional) 2a. Regis trant Information ( Individual, Corp., LLC, Gen. Partner, etc. ) If individual-spell out first, middle and last names (use dash if no middle name) Residence Address (ifCorp. or LLC enter thephysicaladdress of theCorp./LC) City State Zip List State of Corp . /LLC . Must be registered in California 2b. Registrant Information ( Individual, Corp., LLC, Gen. Partner, etc. ) 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./LC) City State Zip 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) Residence Address (if Corp. or LLC enter the physical address of the Corp./LC) City State Zip List State of Corp./LLC. Must be registered in California 3 . This business is conducted by: (If More Than four Registrants - Attach Additional Sheet Showing Owner Information) Individual Married Couple 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 5.Signature(s) (Only one is required) Typed or Printed Name(s) If Limited Liability Comp any/Corporation, Title QC222D 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 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). I HEREBY CERTIFY THAT THIS COPY IS A CORRECT COPY OF THE ORIGINAL STATEMENT ON FILE IN MY OFFICE. RIVERSIDE COUNTY CLERK By, Deputy 2c. Registrant Information ( Individual, Corp., LLC, Gen. Partner, etc. ) 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./LC) City State Zip List State of Corp . /LLC . Must be registered in California ACR 500 (Rev. ) Available in Alternate Formats 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 theCounty Clerk. The statement must be published once a week for four consecutive weeks and an affidavit of publication filed with theCounty Clerk within 30 days after publication has been completed. The statement shall be published in a newspaper of generalcirculation in the County where the principal place of business is located. The statement should be published in a newspaper thatcirculates 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 wholeor 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 - $58.00 for one business name and one registrant plus $2.00 for each additional business at the same address; $2.00 for each additional registrant. Customer copies - $1.00 for the first page and 10242 for each additional page; Certified copies - $2.00. 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 226 (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 226 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 statem