Fictitious Business Name Statement Yuba County Clerk/Recorder th 915 8 St. Ste 107 Marysville, CA 95901-5273 $30.00 ­ For First Business Name and Owner's Name on Statement $5.00 ­ For Each Additional Business Name Doing Business at the Same Location $5.00 ­ For Each Additional Owner's Name New Filing Renewal with Changes Renewal No Changes _______________________ Terry A. Hansen County Clerk's Use Only FILING FEE ALL ITEMS LISTED WITH AN ASTERISK MARK MUST BE COMPLETED THE FOLLOWING PERSON (PERSONS) IS (ARE) DOING BUSINESS AS: * ** Print Fictitious Business Name(s) Street address, City, State & Zip Code of principal place of business in California Mailing address of principal place of business, if different *** REGISTERED OWNER(S): 1. __________________________________ __________________________________ __________________________________ __________________________________ If Corporation or LLC ­ Print State of Incorporation/Organization City State Zip Residence Address Full Name 2. _________________________________ _________________________________ _________________________________ _________________________________ If Corporation or LLC ­ Print State of Incorporation/Organization City State Zip Residence Address Full Name 3. __________________________________ __________________________________ __________________________________ __________________________________ If Corporation or LLC ­ Print State of Incorporation/Organization City State Zip Residence Address Full Name 4. _________________________________ _________________________________ _________________________________ _________________________________ If Corporation or LLC ­ Print State of Incorporation/Organization City State Zip Residence Address Full Name **** THIS BUSINESS IS CONDUCTED BY: (Check one) IF MORE THAN FOUR REGISTRANTS, ATTACH ADDITIONAL SHEET SHOWING OWNER INFORMATION an Individual a General Partnership a Limited Partnership a Limited Liability Company an Unincorporated Association other than a Partnership a Corporation a Trust Copartners Married Couple Joint Venture State or Local Registered Domestic Partners a Limited Liability Partnership ***** The registrant commenced transacting business under the fictitious business name or names listed above on (Insert N/A above if you haven't started transacting business) 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.) Signature: Title: Printed Name: (If corporation, also print corporate title of officer. If LLC, also print title of officer or manager.) 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 EXPIRATION. This statement was filed with the County Clerk of Yuba County on date indicated by filed stamp above. I HEREBY CERTIFY THAT THIS COPY IS A CORRECT COPY OF THE ORIGINAL ON FILE IN MY OFFICE. FILE NUMBER: TERRY A. HANSEN, YUBA COUNTY CLERK BY ____________________________, Deputy EXPIRATION DATE: American LegalNet, Inc. www.FormsWorkFlow.com 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 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, 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 residence address of each domestic partner **** Where four asterisks appear in the form: (a) Check whichever of the terms listed on the front of the form best describes the nature of the business ***** Where five asterisks appear in the form: (a) Insert the date on which the registrant first commenced to transact business under the fictitious business name or names listed, if already transacting business under that name or names (b) Insert N/A if you have not yet commenced to transact business under the fictitious business name or names listed Business and Professions Code Section 17914 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 gen