FICTITIOUS BUSINESS NAME STATEMENT FOR CLERK’S USE BUSINESS AND PROFESSIONS CODE 17900 ET SEQ. Sacramento County Department of Finance Business License Section 700 H Street, Room 1710 Sacramento, CA 95814 (916) 874-6644 $27.00 $ 5.00 $ 5.00 FILING FEES For first business name on statement For each additional business name on this statement at the same location For each owner in excess of one Checks or money orders should be made payable to Sacramento County. 1 TYPE OR PRINT CLEARLY - MUST BE LEGIBLE. PLEASE READ INSTRUCTIONS ON REVERSE SIDE. WHEN FILING BY MAIL, PROVIDE SELF ADDRESSED STAMPED ENVELOPE. Street Address, City, State, Zip of Principal Place of Business. (P.O. Box or PMB not acceptable) County 2 Fictitious Business Name(s) to be Filed (a) (b) (If more than 2 names, attach additional sheet) 3 Full Name/Residence Address of Business Owner(s) (P.O. Box or PMB not acceptable), or Corporation/LLC name and address as registered with Secretary of State (include State where incorporated) Name and Street Address, City, State, Zip (a) (b) (If more than 2 owners, attach additional sheet) 4 This business conducted by: an Individual Married Couple 6 Co-Partners Corporation 5 General Partnership Limited Partnership Limited Liability Company Limited Liability Partnership Joint Venture Trust State or local Registered Domestic Partners Unincorporated Association (other than a partnership) Date you began doing business under the Fictitious Business Name(s) above: ____________________. If you have not started doing business, enter “N/A” (not applicable) here _____________ . I declare that all information in this statement is true and correct. (A business owner who declares as true information which he or she knows to be false is guilty of a crime.) Signature:______________________________________ Title if Corporate Officer: _________________________________ Print Name:________________________________________ Business Phone No. ____________________________ In accordance with Section 17920 (a), a Fictitious Business Name Statement generally expires five years from the date it was filed with the County Clerk, except as provided in Section 17920 (b), 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 (section 14411 et seq., of the Business and Professions Code). This Statement was filed with the County Clerk of Sacramento County on date indicated by file stamp above. I hereby certify that this copy is a correct copy of the original Statement on file in my office. CRAIG A. KRAMER, COUNTY CLERK This Statement expires on: __________________ Rev. 03/10 BY:____________________________________________ Deputy FILE NO. American LegalNet, Inc. www.FormsWorkFlow.com NOTICE TO REGISTRANT PURSUANT TO SECTION 17924 BUSINESS & PROFESSIONS CODE (B & P Code) Within 30 days after the fictitious business name statement has been filed with the County Clerk, the statement must be published in a newspaper of general circulation in the county where fictitious business name was filed. The statement must be published once a week for four successive weeks with at least five days between each date of publication. An affidavit of publication must be filed with the county clerk within 30 days after the completion of the publication. If the registrant has no place of business in this state, the notice shall be published in a newspaper of general circulation in Sacramento County. (Section 17917 B & P Code, Section 6064 Government Code) If refiling is required because the prior statement has expired, the refiling need not be published unless there has been a change in the information in the expired statement, provided the refiling is filed within 40 days of the date the statement expired. (Section 17917 B & P Code) 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 ($1,000.00). (Section 17930 B & P Code) INSTRUCTIONS FOR COMPLETION OF STATEMENT (17913 & 17914 B & P Code) Type or print legibly. (P.O. Box, postal drop box, mailing suite and c/o addresses are not acceptable for either the business or residence address.) 1. Insert the street address and county of the principal place of business in this state. The fictitious business name statement shall be filed with the clerk of the county in which the registrant has his principal place of business in this state or, if the registrant has no place of business in this state, the Fictitious Business Name Statement shall be filed with the Clerk of Sacramento County (Section 17915, B & P Code). 2. Insert the fictitious business name or names if more than one name. Only those businesses operated at the same address may be listed on one statement. 3. Individual: insert full name and residence address of the individual. Married Couple: insert full name and residence address of both spouses. Partnership, co-partnership, joint venture, limited partnership, limited liability partnership, or other association of persons: insert the full name and residence address of each general partner. Trust: insert the full name and residence address of each trustee(s). Corporation: insert the name and address of the corporation as set out in its articles of incorporation, and the state of incorporation. Limited Liability Company (LLC): insert the name and address of the LLC as set out in its articles of organization, and the state of organization. State or local Registered Domestic Partnership: insert full name and residence address of each domestic partner. 4. Indicate which of the terms best describes the ownership of the business. 5. If already transacting business under the fictitious business name or names listed, insert the date on which the registrant first commenced to transact business. If the registrant has not yet commenced to transact business under the fictitious business name or names listed, insert the statement “Not applicable” or “N/A”. 6. If the registrant is an individual, the statement must be signed by the individual; if a partnership or other association of other persons, by a general partner; if a trust, by a trustee; if a corporation, by an officer (title must be indicated); if a limited liability company, by an officer or a manager and indicate his/her title. (Signature of an agent is not acceptable) PLEASE NOTE: THIS OFFICE SERVES ONLY AS A REPOSITORY OF FICTITIOUS BUSINESS NAME STATEMENTS FILED IN SACRAMENTO COUNTY, NEITHER APPROVING OR DISAPPROVING A PARTICULAR NAME, AND CANNOT ACCEPT ANY RESPONSIBILITY FOR ANY OMISSIONS, SIMILARITIES, OR DUPLICATIONS AMONG THE FICTITIOUS BUSINESS NAMES ON FILE. STATE-WIDE REGISTRIES DO NOT EXIST. THE FILING OF A FICTITIOUS BUSINESS NAME STATEMENT DOES NOT GUARANTEE EXCLUSIVE USE OF THAT NAME. IF YOU ARE FILING YOUR STATEMENT BY MAIL, PLEASE INCLUDE A SELF-ADDRESSED, STAMPED ENVELOPE FOR RETURN OF YOUR ENDORSED COPIES. EXPIRATION OF FICTITIOUS BUSINESS NAME STATEMENT (Section 17920 B&P Code) (a) Unless the statement expires earlier under (b) or (c) below, a fictitious business name statement expires five years from the date it was filed in the office of the county clerk. A NEW STATEMENT MUST BE FILED BEFORE THE EXPIRATION DATE. (b) A fictitious business name statement expires 40 days after any change in the facts as set forth in the statement, except (1) a change in the residence address of an individual, general partner, or trustee does not cause the statement to expire, and (2) the filing of a statement of withdrawal from partnership by a withdrawing partner does not cause the statement to expire. A NEW STATEMENT MUST BE FILED WITHIN 40 DAYS AFTER A CHANGE IN THE FACTS. (c) A fictitious business name statement expires when the registrant files a statement of abandonment of use of the fictitious business name statement. ONCE FILED, THE INFORMATION ON THE FICTITIOUS BUSINESS NAME STATEMENT IS PUBLIC RECORD American LegalNet, Inc. www.FormsWorkFlow.com