FILE #_______________________________ TYPE OF FILING (Check one) OFFICE OF THE SUTTER COUNTY CLERK 433 Second Street, Yuba City CA 95991 (530) 822-7134 Original New Filing [Change(s) in facts from previous filing] FICTITIOUS BUSINESS NAME STATEMENT FILING FEE $24.00 FOR FIRST BUSINESS NAME ON STATEMENT $5.00 FOR EACH ADDITIONAL BUSINESS NAME FILED ON SAME $5.00 FOR EACH ADDITIONAL OWNER IN EXCESS OF ONE OWNER STATEMENT AND DOING BUSINESS AT THE SAME LOCATION Refile [No Change(s) in facts from previous filing] Previous file # ________________________ This space reserved for County Clerk The following person (persons) is (are) doing business as: *___________________________________________|________________________________ Print Fictitious Business Name(s) Business Phone # (Optional) **__________________________________________|________________________________ Street address of principal place of business COUNTY Mailing address if different __________________________________________ |_________________________________ City State Zip City State Zip *** REGISTERED OWNER(S): 1. __________________________________ Full Name 2. _________________________________ Full Name __________________________________ Residence Address _________________________________ Residence Address __________________________________ City State Zip _________________________________ City State Zip __________________________________ If Corporation or LLC � Print State of Incorporation/Organization _________________________________ If Corporation or LLC � Print State of Incorporation/Organization 3. __________________________________ Full Name 4. _________________________________ Full Name __________________________________ Residence Address _________________________________ Residence Address __________________________________ City State Zip _________________________________ City State Zip __________________________________ If Corporation or LLC � Print State of Incorporation/Organization _________________________________ If Corporation or LLC � Print State of Incorporation/Organization IF MORE THAN FOUR REGISTRANTS, ATTACH ADDITIONAL SHEET SHOWING OWNER INFORMATION **** THIS BUSINESS IS CONDUCTED BY: (Check one) an Individual a General Partnership a Limited Partnership a Limited Liability Company an Unincorporated Association other than a Partnership a Corporation a Trust Copartners Joint Venture State or Local Registered Domestic Partners a Limited Liability Partnership a Married Couple (Insert N/A above if you haven't started to transact business) ***** The registrant commenced to transact business under the fictitious business name or names listed above on _____________________________ (A registrant who declares as true any material matter pursuant to Section 17913 of the Business and Professions Code that the registrant knows to be false is guilty of a misdemeanor punishable by a fine not to exceed one thousand dollars.) I declare that all information in this statement is true and correct. SIGNATURE OF REGISTRANT __________________________________________________________ ____________________________________________________________________________ Print name of person signing. If corporation, also print corporate title of officer. If LLC, also print title of officer or manager. This statement was filed with the County Clerk of SUTTER COUNTY on the date indicated by the filed stamp in the upper right corner. NOTICE � IN ACCORDANCE WITH SUBDIVISION (a) OF SECTION 17920, A FICTITIOUS 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). I HEREBY CERTIFY THAT THIS COPY IS A CORRECT COPY OF THE ORIGINAL STATEMENT ON FILE IN MY OFFICE. DONNA M. JOHNSTON, COUNTY CLERK Rev. 01/2014 American LegalNet, Inc. www.FormsWorkFlow.com BY:_____________________________________________, Deputy INSTRUCTIONS FOR COMPLETION OF STATEMENT Business and Professions Code Section 17913: * Where one asterisk appears in the form: (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 ** Where two asterisks appear in 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 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 Where three asterisks appear in the form: (a) If the registrant is an individual, insert his or her full name and residence address (b) If the registrants are a married couple, insert the full name and residence address of both parties to the marriage (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 residenc