· · · Filing Fee $23.00 If mailing this form: o Submit original, 2 copies o Self-addressed stamped envelope (Extra postage required) No BLANK or NOT TO EXCEED checks are accepted 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 STATEMENT OF ABANDONMENT OF USE OF FICTITIOUS BUSINESS NAME See reverse for instructions ­ The information you provide is public record The following person(s) has/have abandoned the use of the Fictitious Business Name Fictitious Business Name(s) _______________________________________________________________________________________________________________ Phone: (Optional) _______________________________________________________________________________________________________________ Street Address of Principal Place of Business Mailing Address (if different) City ______________________________________________________________________________________________________________ State Zip County City State Zip County Full Name of Registrant Residence Address City State Zip Code Full Name of Registrant Residence Address City State Zip Code Full Name of Registrant Residence Address City State Zip Code Full Name of Registrant Residence Address City State Zip Code The Fictitious Business Name above was filed in Shasta County on: _______________________________________________________ This business is conducted by: (check one only) An Individual A Married Couple Co-Partners Joint Venture A Limited Liability Partnership A Trust A Limited Partnership A General Partnership A Limited Liability Company A Corporation An Unincorporated Association other than a Partnership State or Local Registered Domestic Partners 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 ___________________________________________________ Type or Print Name _____________________________________________________ Corporation or Limited Liability Company Name State of Incorporation Section 17922 Business & Professions Code - 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. County Use: Mail ID American LegalNet, Inc. www.FormsWorkFlow.com THE INSTRUCTIONS BELOW ARE NOT TO BE PUBLISHED (Sec. 17924 B&P) INSTRUCTIONS FOR COMPLETION OF STATEMENT Section 17922 Business & Professions Code 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. 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) If the registrant is an Individual, insert his or her full name and residence address If the registrants are Husband and Wife, insert the full name and residence address of both the husband and the wife If the registrant is a General Partnership, Limited Partnership, Copartners, a Limited Liability Partnership, a Joint Venture, or an Unincorporated Association other than a Partnership, insert the full name and residence address of each general partner 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. If the registrant is a Trust, insert the full name and residence address of each trustee 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 If the registrants are State or Local Registered Domestic Partners, insert the full name and residence address of each domestic partner 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 The Statement of Abandonment of fictitious business name must be published in a newspaper once a week for four successive weeks and an affidavit of publication filed with the county clerk within 30 days after publication has been accomplished. The statement should be published in a newspaper of general circulation in the county where the principal place of business is located. The statement should be published in such county in a newspaper that circulates in the area where the business is conducted (Business & Professions Code 17917)." 17924 (2) "Any person who executes, file, 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)" American LegalNet, Inc. www.FormsWorkFlow.com