Kenneth W. Blakemore, MAI Recorder / County Clerk County of San Joaquin 44 North San Joaquin Street, Suite 260 Stockton, CA 95202 (209) 468-3939 SEE REVERSE SIDE FOR INSTRUCTIONS Original (First Filing) Refile (Change(s) in facts from previous filing) Refile (No Change(s) in facts from previous filing) Previous File # ________________ REMINDER 1. 2. 3. 4. 5. 6. 7. Type or print legibly in black ink Submit original and 2 copies. The $33 filing fee includes one owner and one business name. Add $6 for each additional owner or partner. Add $6 for each additional business name located at the same address If filing by mail, enclose a self addressed, stamped, return envelope Attach separate page for additional names Space above for use of County Clerk only FICTITIOUS BUSINESS NAME STATEMENT The following person (persons) is (are) doing business as: A FICTITIOUS BUSINESS NAME(S) 1) 2) Street Address of Principal place of Business (P.O. Box not acceptable) B City State Zip Mailing Address (If Different) City State Zip Full Name of Registrant (if Registrant is a Corporation, show Corporation name) Full Name of Registrant Residence Street Address (P.O. Box not acceptable) Residence Street Address (P.O. Box not acceptable) City State Zip City State Zip (If corporation or LLC, print state of incorporation/organization) Full Name of Registrant Full Name of Registrant Residence Street Address (P.O. Box not acceptable) C (If corporation or LLC, print state of incorporation/organization) Residence Street Address (P.O. Box not acceptable) City State Zip (If corporation or LLC, print state of incorporation/organization) D This Business is conducted by: (Check only one)  an individual  husband and wife  co-partners  a trust  joint venture  a corporation City State Zip (If corporation or LLC, print state of incorporation/organization)  a limited partnership  a general partnership  limited liability company  an unincorporated association other than a partnership  a limited liability partnership  State or Local Registered Domestic Partners  The registrant commenced to transact business under the fictitious business name or names listed above on ____________________________ E (Insert N/A above if you haven’t started to transact business) NOTICE – IN ACCORDANCE WITH SUBDIVISION (a) OF SECTION 17920, A FICTITIOUS NAME I declare that all information in this statement is true and correct. (A registrant who declares as true information which he or she knows to be 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 false is guilty of a crime.) _____________________________________________________ SIGNATURE OF REGISTRANT F 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 THIS STATEMENT WAS FILED WITH THE RECORDER / COUNTY CLERK OF SAN FICTITIOUS BUSINESS NAME IN VIOLATION OF THE RIGHTS OF ANOTHER UNDER FEDERAL, STATE, JOAQUIN COUNTY ON THE DATE INDICATED BY THE FILE STAMP IN THE UPPER OR COMMON LAW (SEE SECTION 14411 ET SEQ., BUSINESS AND PROFESSIONS CODE). RIGHT CORNER. Print name of person signing. If corporation, also print corporate title of officer. If LLC, also print title of officer or manager. I hereby certify that this copy is a correct copy of the original statement on file in my office. Assessor/Recorder/County Clerk Registrant’s Name _____________________________________ (Please Print) Officer’s Title _________________________________________ By,_______________________________________________, Deputy (Please Print) San Joaquin County Assessor/Recorder/County Clerk 277 (07/2012) Original- Recorder Yellow-Newspaper Pink - Customer American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR COMPLETION OF STATEMENT Business and Professions Code Section 17913: SECTION A: (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 SECITON B: (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 SECTION C: (a) If the registrant is an individual, insert his or her full name and residence address (b) If the registrants are husband and wife, insert the full name and residence address of both the husband and the wife (c) If the registrant is a general partnership, copartnership, 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 SECTION D: (a) Check whichever of the terms listed on the front of the form that best describes the nature of the business. Corporations and limited liability companies must include state filed Articles of Incorporation. State Articles also required when re-filing Fictitious Business Name Statement. SECTION E: (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 SECTION F: 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 the husband or wife (c) If the registrant is a general partnership, limited partnership, limited liability partnership, copartnership, joint venture, or unincorporated association other than a partnership, by a general partner (d) If the registrant is a limited liability company, by a manager or officer (e) If the registrant is a trust, by a trustee (f) If the registrant is a corporation, by an officer (g) If the registrant is a state or local registered domestic partnership, by one of the domestic partners Business and Professions Code Section 17915 The fictitious business name statement shall be filed with the clerk of the county in which the registrant has his or her principal place of business in this state or, if the registrant has no place of business in this state, with the Clerk of Sacramento County. Nothing in this chapter shall preclude a person from filing a fictitious business name statement in a county other than that where the principal place of business is located, as long as the requirements of this subdivision are also met. Business and Professions Code Section 17917 Publication for Original, New Filings (renewal with change in facts from previous filing), or Refile (a) Within 30 days after a fictitious business name statement has been filed, the registrant shall cause it to be published in a newspaper of general circulation in the county where the fictitious business name statement was filed or, if there is no such newspaper in that county, in a newspaper of general circulation in an adjoining county. If the registrant does not have a place of business in this state, the notice shall be published in a newspaper of general circulation in Sacramento County. The publication must be once a week for four successive weeks and an affidavit of publication must be filed with the county clerk where the fictitious business name statement was filed within 30 days after the completion of the publication. (b) If a refiling is required because the prior statement has expired, the refiling need not be published, unless there has been a change in the information required in the expired statement, provided the refiling is filed within 40 days of the date the statement expired. Business and Professions Code Section 17922 Abandonment of Fictitious Business Name (a) Upon ceasing to transact business in this state under a fictitious business name that was filed in the previous five years, a person who has filed a fictitious business name statement shall file a statement of abandonment of use of fictitious business name. The statement shall be executed and published 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 or her fictitious business name statement. Business and Professions Code Section 17930 Any person who executes, files, or publishes any statement under this chapter, knowing that such statement is false, in whole or in part, shall be guilty of a misdemeanor and upon conviction thereof shall be punished by a fine not to exceed one thousand dollars ($1,000). San Joaquin County Assessor/Recorder/County Clerk 277 (07/2012) Original- Recorder Yellow-Newspaper Pink - Customer American LegalNet, Inc. www.FormsWorkFlow.com