SEE BACK SIDE FOR INSTRUCTIONS Fictitious Business Name (FBN) Statement (includes registration of 1 business name, 1 or 2 registrants and 1 certified copy)…...........................................…. $40.00 Each additional business name and/or registrant (must have the same business address and registrant) on the same statement ......................................................... $7.00 FOR COUNTY CLERK-RECORDER'S USE FICTITIOUS BUSINESS NAME FILED WITH THE COUNTY CLERK-RECORDER OF SANTA CLARA COUNTY ON THE DATE IDENTIFIED ON THE FILING LABEL The following person (persons) is (are) doing business as: (Use the ADDENDUM page to list additional fictitious business names.) 1. FICTITIOUS BUSINESS NAME at: 2. (DO NOT USE P.O. BOX, PRIVATE MAIL BOX ADDRESSES) STREET ADDRESS OF PRINCIPAL PLACE OF BUSINESS CITY STATE ZIP COUNTY If the principal place of business identified in #2 above is not in Santa Clara County, a current fictitious business name statement for the fictitious business name(s) identified in #1 above shall be on file at the above-identified County that is the principal place of business. If applicable, please complete #3 below: 3. THE PRINCIPAL PLACE OF BUSINESS IS IN _______________________________ COUNTY AND A CURRENT FICTITIOUS BUSINESS NAME STATEMENT IS ON FILE AT THE COUNTY CLERK-RECORDER'S OFFICE OF SAID COUNTY. This business is owned by: 4. (An asterisk (*) item requires proof of registration with the California Secretary of State's Office) AN INDIVIDUAL A GENERAL PARTNERSHIP *A LIMITED PARTNERSHIP AN UNINCORPORATED ASSOCIATION OTHER THAN A PARTNERSHIP MARRIED COUPLE JOINT VENTURE * A CORPORATION *A LIMITED LIABILITY COMPANY A TRUST STATE OR LOCAL REGISTERERED DOMESTIC PARTNERS COPARTNERS *LIMITED LIABILITY PARTNERSHIP The name and residence address of the registrant(s) is (are): (DO NOT USE P.O. BOX, PRIVATE MAIL BOX ADDRESSES) NOTE: General Partnerships, Copartnership, Joint Venture, Limited Liability Partnership, Unincorporated Association, and Limited Partnership - Insert name and residence address of each General Partner, Trusts - Insert the full name and resident address of each trustee; Limited Liability Company and Corporation - Insert full name and address of Limited Liability Company or Corporation as registered with the California Secretary of State's Office; State or local registered Domestic Partners - Insert full name and residence address of each Domestic Partner. USE THE ADDENDUM PAGE TO LIST ADDITIONAL NAMES AND ADDRESSES 5. NAME ADDRESS CITY STATE ZIP NAME ADDRESS CITY STATE ZIP This filing is a: Registrant began transacting business under the fictitious business name(s) listed above on: 6. DATE: ______________________ NOT APPLICABLE 7. First Filing (Publication Required) Refile of previous file # __________________ (check appropriate box, below) Refiled prior to expiration or within 40 days past expiration, with NO CHANGES With changes (Publication Required) After 40 days of expiration date (Publication Required) Due to publication requirement not met on previous filing (Publication Required) I hereby certify that this copy is a correct copy of the original Fictitious Business Name Statement on file in my office. Regina Alcomendras, Santa Clara County Clerk-Recorder By ________________________________________ , Deputy Dated: _________________________ CLERK-RECORDER SEAL 8. 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 false is guilty of a crime.) SIGNED X ____________________________________________________ PRINTED NAME _______________________________________________________ If a CORPORATION, LIMITED LIABILITY COMPANY, LIMITED PARTNERSHIP or LIMITED LIABILITY PARTNERSHIP, the following must be completed: ENTITY NAME _________________________________________________ TITLE / CAPACITY OF SIGNER ___________________________________________ ARTICLE / REG #______________________(from CA Sec of State's Office) ABOVE ENTITY WAS FORMED IN THE STATE OF ____________________________ 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 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 (SEE SECTION 14411 ET SEQ., BUSINESS AND PROFESSIONS CODE). Rev. 3 - 6/17/2015 American LegalNet, Inc. www.FormsWorkFlow.com SANTA CLARA COUNTY CLERK-RECORDER'S OFFICE: www.clerkrecorder.org INSTRUCTIONS FOR COMPLETION - FORM MUST BE LEGIBLY COMPLETED USING BLACK INK ONLY NOTE: This office will always send information addressed to the business name and address identified in section #1 and #2. 1. FICTITIOUS BUSINESS NAME(S): Insert the exact NAME OF THE BUSINESS. Please use an addendum page if you are registering more than 1 business names. All business names on the same filing must have the same business address and registrant. If the BUSINESS NAME includes the words CORPORATION, CORP., INC., LIMITED LIABILITY COMPANY, LIMITED LIABILITY PARTNERSHIP, LIMITED PARTNERSHIP or any abbreviation indicating such business entity, i.e., LLC, LLP, or LP., the ownership entity identified in section #4 must also be the same business entity type. 2. ADDRESS OF BUSINESS: Insert the street address of the principal place of business in California, including the county. DO NOT USE P.O. BOX, RENTAL DROP BOXES, PMB'S, C/O (IN CARE OF) ADDRESSES. If the registrant has no place of business in California, the proper place to file the Fictitious Business Name Statement is with the Clerk-Recorder’s Office of Sacramento County. 3. PRINCIPAL PLACE OF BUSINESS: Fictitious Business Name Statements must be filed in the county that is the principal place of business prior to subsequent filings for the same name in other counties. If the principal place of business identified in section #2 is not in Santa Clara County, mark the box and insert the name of the county that is the principal place of business where the current Fictitious Business Name statement is filed for the fictitious business name(s) being filed on this statement. 4. TYPE OF BUSINESS OWNERSHIP: Check the box which best describes the business organization/type that is conducting the business. NOTE: Corporations, Limited Liability Companies, Limited Liability Partnerships and Limited Partnerships require proof of registration with the California Secretary of State’s Office. 5. REGISTRANT NAME(S) AND ADDRESS: Insert SEPARATELY (one name per section) the name and address of each registrant as identified below. Do NOT use P.O.Box, rental mail/drop box, PMB or ℅ addresses. If the registrant is: an individual -insert his or her full name and residence address; married couple - insert the full name and residence address of the married couple; 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; limited partnership - insert the full name and residence address of each general partner; 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 California Secretary of State; trust - insert the full name and residence address of each trustee; corporation insert the name and address of the corporation, as identified in its articles of incorporation on file with the California Secretary of State; state or local registered domestic partners - insert the full name and residence address of each domestic partner. 6. DATE OF COMMENCEMENT OF BUSINESS: If you have already started to transact business under the fictitious business name being registered, check the first box and enter the date started. Check the second box if you have not yet begun. 7. FILING STATUS: Please check the appropriate box. If this filing is a REFILE or RENEWAL, insert the Previous File Number and check the applicable box. 8. SIGNATURES: The statement shall be signed as follows: If the registrant is: an individual - by the individual; married couple – by either one of the couple; general partnership, limited partnership, limited liability partnership, copartnership, joint venture, or unincorporated association other than a partnership - by a general partner; limited liability company - by a manager or officer; trust - by a trustee; corporation - by an officer; state or local registered domestic partnership - by one of the domestic partners. Corporations, limited liability companies, limited partnerships and limited liability partnerships must also complete additional information regarding entity name, title/capacity of signer, article/registration # from CA Secretary of State, and the name of the state where the entity was formed. FILING FEES: See Top Front Left (FEES Subject to Change Without Notice) If filing by mail, include a check for the appropriate fee made payable to Clerk-Recorder's Office and send this completed, signed statement with a self-addressed stamped envelope to: Clerk-Recorder's Office, Business Division, 70 West Hedding Street, East Wing, First Floor , San Jose, CA 95110 PLEASE NOTE THE FOLLOWING EXCERPTS FROM THE CALIFORNIA BUSINESS AND PROFESSIONS (B & P) AND GOVERNMENT CODES: B & P § 17917. (a, b) Within 30 days after a fictitious business name statement has been filed pursuant to this chapter, the registrant shall cause a statement… to be published pursuant to Section 6064 of the Government Code in a newspaper of general circulation… that circulates in the area where the business is to be conducted… in the county where the fictitious business name statement was filed… (d) An affidavit showing the publication of the statement shall be filed with the county clerk where the fictitious business name statement was filed within 30 days after the completion of the publication. Government Code § 6064. Publication of notice pursuant to this section shall be once a week for four successive weeks. B & P § 17922. (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. B & P § 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). CALIFORNIA BUSINESS AND PROFESSIONS CODE SECTIONS 17900 - 17930 (Fictitious Business Name Statement), can be viewed at the following website: www.leginfo.ca.gov Rev. 3 - 6/17/2015 American LegalNet, Inc. www.FormsWorkFlow.com