Rev. 02/01/18 Registrant / Corporation / Limited Liability Company Name Residence / Corporation / Limited Liability Company Address City State Zip Code Registrant / Corporation / Limited Liability Company Name Residence / Corporation / Limited Liability Company Address City State Zip Code Registrant / Corporation / Limited Liability Company Name Residence / Corporation / Limited Liability Company Address City State Zip Code Registrant / Corporation / Limited Liability Company Name Residence / Corporation / Limited Liability Company Address City State Zip Code FICTITIOUS BUSINESS NAME STATEMENT See reverse for instructions The information you provide is public record The following person(s) is (are) doing business as: Please Print or type 1* Fictitious Business Name(s) A. B. 2 ** Business Address Mailing Address (if different) City State Zip County City State Zip County 3*** 4**** This business is conducted by: (check one only) An Individual A Limited Liability Partnership A Limited Liability Company A Married Couple A Trust A Corporation Co-Partners A Limited Partnership An Unincorporated Association other than a Partnership Joint Venture A General Partnership State or Local Registered Domestic Partners 5***** The registrant(s) commenced to transact business under the fictitious business name(s) listed above on (MM/DD/CCYY) . (Write N/A if you have not started to transact business) 6 By signing below, I declare that all information in this statement is true and correct. A registrant who executes this statement knowing that such statement is false in whole/in part shall be guilty of a misdemeanor punishable by a fine not to exceed one thousand dollars ($1,000). Signature If a Corporation or Limited Liability Company Name Type or Print Name & Title State of Incorporation NOTICE THIS FICTITIOUS BUSINESS NAME STATEMENT GENERALLY EXPIRES FIVE YEARS FROM THE DATE IT WAS FILED IN THE OFFICE OF THE COUNTY CLERK. 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). COUNTY USE ONLY New Statement Filing Statement Renewal Statement Renewal with Changes By Mail Check ID Phone: (Optional) CATHY DARLING ALLEN Shasta County Clerk 1643 Market Street Redding, CA 96001 PO Box 990880, Redding, CA 96099 - 0880 530 - 225 - 5730 CA Relay Service 711 or 800 - 735 - 2922 One Business Name & O ne Registrant $54 .00 o Each ADDITIONAL Business Name $ 9 .00 o Each ADDIT I ONAL Registrant $ 9 .00 If mailing this form: Submit o riginal, 3 copies and self - addressed stamped envelope (Extra postage required) No BLANK or NOT TO EXCEED checks are accepted American LegalNet, Inc. www.FormsWorkFlow.com Rev. 02/01/18 INSTRUCTIONS FOR COMPLETION OF STATEMENT BUSINESS AND PROFESSIONS CODE 24717913 *Where one asterisk appears in the form on the front side: a) Insert the fictitious business name or names. b) Only those businesses operated at the same address by the same owners may be listed on the same statement. **Where two asterisks appear on the front side of the form: 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 the statement with the Clerk of Sacramento County. c) Mail Box and P.O. Box Numbers are not acceptable as business addresses, when used alone without a street address. *** Where three asterisks appear on the front side of the form: 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, co-partnership, 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 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 registrant is a trust, insert the full name and resident 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. **** Where four asterisks appear in the form on the front side: a) Indicate which best describes the nature of the business. ***** Where five asterisks appear in the form on the front side: a) Insert the date on which registrant commenced to transact business under the fictitious business name or names listed, if already transacting business under that name or names. b) If the registrant has not yet commenced to transact business under the fictitious business name or names listed, Signature a) 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 limited liability company, by a manager or officer; if a trust, by a trustee; if a corporation, by an officer; if a state/local registered domestic partnership, by one of the domestic partners. BUSINESS AND PROFESSIONS CODE 247 17914 INSTRUCTION ON PUBLICATION FIRST FILINGS: Within 30 days after the 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 was filed. The publication must be once a week for four successive weeks and an affidavit of publication filed with the county clerk within 30 days after the completion of the publication. The newspaper selected should be one that circulates in the area where the business is to be conducted. (Business & Professions Code 247 17917) (Paraphrased). RENEWAL: If any change has occurred in the facts in your original statement, your new statement is deemed to be a first filing; therefore, it must be published as required above. If no changes have occurred, publication is not required if filed within 40 days of expiration of current statement. An affidavit showing the publication of the statement shall be filed with the county clerk within 30 days after the completion of the publication. ABANDONMENT 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 & Professional Code 247 17922) BUSINESS & PROFESSIONS CODE 247 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 ($1,000.00). THE INFORMATION YOU PROVIDE BECOMES PUBLIC RECORD UPON FILING American LegalNet, Inc. www.FormsWorkFlow.com