P.O. Box 751, Riverside, CA 92502-0751 -- (951) 486-7000 82-675 Hwy. 111, Rm. 113, Indio, CA 92201 -- (760) 863-8732 Assessor, County Clerk-Recorder OFFICE OF THE COUNTY CLERK STATEMENT OF ABANDONMENT OF USE OF FICTITIOUS BUSINESS NAME Page __1__ of _____ --USE BLACK INK ONLY -- MUST BE TYPED OR PRINTED County of Riverside FILING FEE $27.00 Receipt # _________________ The following fictitious business name(s) has been abandoned by the following person(s): 1a. FILE NO. __________________________________ _____________________________________________________________________________________________________________________________ 1b. Fictitious Business Name(s) to be Abandoned at Same Address - Attach supplemental Sheet Provided by Clerk's Office if Necessary ______________________________________________________________________________________________________________________________ 1c. Business Address, City, State and Zip Code, AND COUNTY of Principal Place of Business (No P.O. or Mail Boxes) 2. _______________________________________________________________ Full Name of Registrant - First, Middle and Last _______________________________________________________________ Full Name of Registrant - First, Middle and Last _______________________________________________________________ Residence Address _______________________________________________________________ Residence Address _______________________________________________________________ City State Zip _______________________________________________________________ City State Zip _______________________________________________________________ (If corporation or limited liability company, state of incorporation or organization) _______________________________________________________________ (If corporation or limited liability company, state of incorporation or organization) _______________________________________ _______________________ Full Name of Registrant - First, Middle and Last _______________________________________________________________ Full Name of Registrant - First, Middle and Last _______________________________________________________________ Residence Address _______________________________________________________________ Residence Address _______________________________________________________________ City State Zip _______________________________________________________________ City State Zip _______________________________________________________________ _______________________________________________________________ (If corporation or limited liability company, state of incorporation or organization) (If corporation or limited liability company, state of incorporation or organization) 3. This business is conducted by: (If More Than 4 Registrants - Attach Additional Sheet Showing Owner Information) Individual Husband & Wife Trust Corporation a Limited Partnership Co-Partners Joint venture Limited Liability Company/Partnership an Unincorporated Association - other than a Partnership State or Local Registered Domestic Partnership a General Partnership Other 4. The fictitious business name(s) referred to above was filed in Riverside County on ________________________________________________________ 5. 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.) Signature ________________________________________________________________________________________________________________________ Typed or Printed Name _____________________________________________________________________________________________________________ If Limited Liability Company/Corporation - Title ________________________________________________________________________________________ This statement was filed with the County Clerk of Riverside County on date indicated by file stamp above. SEE REVERSE SIDE FOR INSTRUCTIONS Form 502 / ACR 863P-AS4CL0 (Est. 01/2008) American LegalNet, Inc. www.FormsWorkflow.com THE INSTRUCTIONS BELOW ARE NOT TO BE PUBLISHED (Sec. 17922 and 17924, Business & Professions Code) INSTRUCTIONS FOR COMPLETION OF STATEMENT Section 17922 Business & Professions Code (1a-c) The file number of the filing being abandoned, the business name being abandoned and the street address of the principal place of business. (2.) In the case of an individual, the full name and address of the individual is to be inserted. In the case of a partnership or other association of persons, the full names and addresses of ALL the general partners are to be inserted. In the case of a corporation or limited liability company, the name of the corporation or the limited liability company as set forth in it's articles of incorporation or articles of organization, the Sate of incorporation or organization, and the Limited Liability Articles of Organization /Articles of Incorporation Number. In the case of a business trust, the full name and residence address of each of the trustees are to be inserted. (Attach additional sheet if necessary.) (3.) Mark the box that best describes the nature of the business being abandoned. (4.) Insert date the fictitious business name statement was filed in Riverside County. (5.) If the registrant is an individual, the statement shall be signed by the individual; if a partnership or other association of persons, by a general partner; if a business trust, by a trustee; if a corporation, by an officer; if a limited liability company, by a manager or officer. (Section 17914 Business & Professions Code.) ............................................................................................................................................................. NOTICE Section 17922 Business & Professions Code (a) A person who has filed a fictitious business name statement may, upon ceasing to transact business in this state under that fictitious business name, file a statement of abandonment of use of fictitious business name. The statement 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 person has filed his fictitious business name statements. 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. If the file number begins with an "R", your document should be filed in the Riverside office. If the number begins with an "I", your document should be filed in Indio. (See front of form for addresses) Form 502 / ACR 863P-AS4CL0 (Est. 01/2008) American LegalNet, Inc. www.FormsWorkflow.com