SEE BACK SIDE FOR INSTRUCTIONS FOR COUNTY CLERK-RECORDER'S USE (FBN) Statement of Abandonment (includes registration of 1 business name, 1 or 2 registrants, and 1 certified copy)......................................................................... $37.00 Each additional business name and/or registrant (must have the same business address and registrant) on the same statement.................................................................... $7.00 STATEMENT OF ABANDONMENT OF USE OF FICTITIOUS BUSINESS NAME The following person(s) / registrant(s) has / have abandoned the use of the fictitious business name(s). FORM MUST BE TYPED OR LEGIBLY COMPLETED USING BLACK INK ONLY. FICTITIOUS BUSINESS NAME ADDRESS CITY / STATE / ZIP FILED IN SANTA CLARA COUNTY ON FULL NAME of Registrant(s): 1. (STREET ADDRESS OF PRINCIPAL PLACE OF BUSINESS) (DATE) UNDER FILE NO. (PREVIOUS FILE NUMBER) (Refer to the back of this form for instructions.) _____________________________________________ (FULL NAME) 2. _____________________________________________ (FULL NAME) _____________________________________________ (ADDRESS) _____________________________________________ (ADDRESS) _____________________________________________ (CITY / STATE / ZIP) _____________________________________________ (CITY / STATE / ZIP) 3. _____________________________________________ (FULL NAME) 4. _____________________________________________ (FULL NAME) _____________________________________________ (ADDRESS) _____________________________________________ (ADDRESS) _____________________________________________ (CITY / STATE / ZIP) _____________________________________________ (CITY / STATE / ZIP) This business was conducted by: An Individual COPartners Married Couple Joint Venture A Limited Partnership A General Partnership A Corporation A Trust An Unincorporated Association Other Than a Partnership A Limited Liability Company Limited Liability Partnership State or Local Registered Domestic Partners 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_______________________________________________________ (Type / Print Signature) ____________________________________________ I hereby certify that this copy is a correct copy of the original STATEMENT OF ABANDONMENT on file in my office. Regina Alcomendras, Santa Clara County Clerk-Recorder By __________________________________________________ Deputy CLERK-RECORDER SEAL Dated: _________________________ This statement was filed with the County Clerk-Recorder of Santa Clara County on the date indicated by the filing label above. SANTA CLARA COUNTY CLERK-RECORDER'S OFFICE: www.clerkrecorder.org Rev. 2 - 4/9/2015 American LegalNet, Inc. www.FormsWorkFlow.com INFORMATION and INSTRUCTIONS FOR COMPLETING THE STATEMENT OF ABANDONMENT These instructions are not required to be published (Business and Professions Code § 17924 (a)(2)). The form must be typed or legibly completed using BLACK INK only. APPLICABLE CALIFORNIA BUSINESS and PROFESSIONS CODE SECTIONS 17920 (c) A fictitious business name statement expires when the registrant files a statement of abandonment of the fictitious business name described in the statement. 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). 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. 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 or her fictitious business name statement. 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. (b) The statement shall include: (1) The name being abandoned and the street address of the principal place of business. (2) The date on which the fictitious business name statement relating to the fictitious business name being abandoned was filed, the file number, and the county where filed. (3) In the case of an individual, the full name and residence address of the individual. (4) In the case of a married couple, the full name and residence address of the married couple. (5) In the case of a general partnership, a limited partnership, copartners, a limited liability partnership, a joint venture, or an unincorporated association other than a partnership, the full names and residence addresses of all of the general partners. (6) In the case of a corporation, the name and address of the corporation as set forth in its articles of incorporation on file with the California Secretary of State. (7) In the case of a trust, the full name and residence address of each of the trustees. (8) In the case of a limited liability company, the name and address of the limited liability company as set forth in its articles of organization on file with the California Secretary of State. (9) In the case of state or local registered domestic partners, the full name and residence address of each domestic partner. 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. FORM INSTRUCTIONS (Business and Professions Code § 17922) Fictitious Business Name - Insert all of the fictitious business names that appeared on the fictitious business name statemen