Business & Professions Code Section 17922 Upon ceasing to transact business in this state under a fictitious business name that was filed in the previous five years, a person who filed a fictitious business name statement shall file a statement of abandonment of use of a 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. Phone No. ( ) _____________________ (Phone number will be kept confidential) INSTRUCTIONS STATEMENT of ABANDONMENTof Use of a Fictitious Business Name Please read all information below BEFORE completing the application! Please provide the following information on the application: The fictitious name being abandoned, the street address and county of the principal place of business. The date on which the fictitious business name (FBN) statement relating to this abandonment was filed. The file number of the original fictitious business name statement. The above information is located on the original FBN statement. It can also be found in the FBN indices located on our website www.yolorecorder.org, or in our office. List all registrants and their physical residence addresses. If a... A Married Couple, the full name and residence address of both the parties to the marriage. Partnership, or other association of persons, the full names and residence addresses of all the general partners is required. Corporation, the name and address of the corporation, as set forth in its articles of incorporation and state of corporation are required. Trust, the full name and residence address of each trustee is required. Limited Liability Company, the name and address of the limited liability company as set out in its articles of organization and state of organization are required. State of Local Registered Domestic Partners, the full name and residence address of both domestic partners. Your filed Statement of Abandonment must be published in a newspaper, once a week, for four (4) consecutive weeks and an affidavit of publication filed with the County Clerk when publication has been accomplished. (Business & Professions [B&P] Code Section 17917) Once your Statement has been filed with the County Clerk/Recorder and you have been issued three (3) certified copies, NO changes, additions or corrections may be made to this statement. If any alterations need to be made you will need to file a NEW Statement of Abandonment and pay a new $55 filing fee. Any person who executes, files, or publishes any fictitious business name, abandonment, or withdrawal 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). (B&P Code Section 17930) THE INFORMATION CONTAINED ON THIS PAGE IS NOT CONSIDERED PART OF THE ORIGINAL DOCUMENT AND IS NOT TO BE PLUBLISHED (B&P Code Section 17917) American LegalNet, Inc. www.FormsWorkFlow.com For Office Use Only STATEMENT of ABANDONMENT of USE of FICTITIOUS BUSINESS NAME Jesse Salinas, County Clerk/Recorder Yolo County Clerk/Recorder 625 Court Street, Room #B01 - Woodland CA 95695 (530) 666-8130 FBN Number Please Print or Type The person(s) or entity listed below are abandoning the use of the following fictitious business name(s): Name of Business(es) _______________________________________________________________ ______________________________________________________________________________________________________________ Physical Street Address (No P. O. Box) City St Zip County The fictitious business name was originally filed in Yolo County on ________________ and is being ABANDONED by the registrant(s) listed below: (date) 1. __________________________________________ Full Name of Registrant (print or type) 2. _____________________________________________ Full Name of Registrant (print or type) __________________________________________ Residence Physical Street Address _____________________________________________ Residence Physical Street Address __________________________________________ City St Zip County _____________________________________________ City St Zip County If additional registrants need to be listed please attach sheet(s) showing each registrant's name and address information. If a Corporation or Limited Liability Company (LLC), please indicate the corporation or LLC name, as set forth in the articles of incorporation or organization on file with the California Secretary of State and State of incorporation or organization along with the address and county of the principal place of business: ______________________________________________________________________________________________________________ Corporation or LLC Name Physical Street Address City St Zip County The business was conducted by: (check one) [ ] An Individual [ ] Corporation [ ] A Trust [ ] Unincorporated Association other that a Partnership [ ] General Partnership [ ] Joint Venture [ ] Limited Liability Company [ ] Limited Partner [ ] Co-partners [ ] A Married Couple [ ] 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.) Registrant Signature ______________________________________ If corporation, also print corporate title(s) of officer(s). Print or Type Name _____________________________________ If LLC, also print registrant(s) title(s). See Instructions on reverse side I hereby certify that this is a true copy of the original document on file in this office. This certification is true as long as there are no alterations to the document, AND as long as the document is sealed with a red seal. State of California County of Yolo Jesse Salinas, County Clerk/Recorder Filing Fee: $55.00 American LegalNet, Inc. www.FormsWorkFlow.com By: ______________________________________ Deputy Clerk/Recorder Date _____________________