FILE TO RENEW NOW: FICTITIOUS NAME WILL EXPIRE ON 12/31/17 FLORIDA DEPARTMENT OF STATE SECRETARY OF STATE DIVISION OF CORPORATIONS APPLICATION FOR RENEWAL OF FICTITIOUS NAME REGISTRATION # 1. Fictitious Name to be Renewed Mailing Address of Business City State Zip Code CHECK HERE IF MAKING CHANGES CR4E003 (4/17) If above mailing address is incorrect in any way, line through incorrect information and enter correction in Block 2. 3. FEI Number 2. Mailing Address change if applicable: 4. County of Principal Place of Business Suite, Apt. #, etc. 5. Date Registered City State Zip Code 6. Certificate of Status Desired: $10 Additional Fee Required AN OWNER THAT IS A CORPORATION, LIMITED PARTNERSHIP OR OTHER BUSINESS ENTITY MUST BE REGISTERED AND ACTIVE WITH THIS OFFICE. 7. CURRENT OW NER (S) . DOCUMENT # FEI # NAME STREET ADDRESS CITY- ST- ZIP DOCUMENT # FEI # NAME STREET ADDRESS CITY- ST- ZIP DOCUMENT # FEI # NAME STREET ADDRESS CITY- ST- ZIP DOCUMENT # FEI # NAME STREET ADDRESS CITY- ST- ZIP 8. ADDITIONS / CHANGES TO OW NERS DELETE DOCUMENT # FEI # NAME STREET ADDRESS CITY- ST- ZIP Change Addition DELETE DOCUMENT # FEI # NAME STREET ADDRESS CITY- ST- ZIP Change Addition DELETE DOCUMENT # FEI # NAME STREET ADDRESS CITY- ST- ZIP Change Addition DELETE DOCUMENT# FEI # NAME STREET ADDRESS CITY- ST- ZIP Change Addition 9. I (we) the undersigned, being the sole (all the) party (ies) owning interest in the above fictitious name, certify that the information indicated on this form is true and accurate. I (we) understand that the signature(s) below shall have the same legal effect as if made under oath. I further certify that the names of individuals listed on this form do not qualify for an exemption contained in section 119, Florida Statutes. (At least one signature required). I am aware that false information submitted in a document to the Department of State constitutes a third degree felony as provided for in s.817.155, F.S. Signature of Owner Date Email address: (to be used for future renewal notification) American LegalNet, Inc. www.FormsWorkFlow.com MAKE CHECK PAYABLE TO DEPARTMENT OF STATE FILING FEE $50.00 PLEASE READ ALL INSTRUCTIONS CAREFULLY BEFORE COMPLETING THE FORM. IF YOU NEED ASSISTANCE, PLEASE CALL (850)245-6059. INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR RENEWAL Block 1: Block is preprinted with the fictitious name, the registration number and mailing address of the business as it was originally registered with this office. The name of the business cannot be changed on the statement of renewal. A cancellation/re-registration must be filed. Please call (850)245-6059 for the appropriate form. Block 2: If the mailing address printed in block 1 is incorrect, enter mailing address in block 2. This address does NOT have to be the principal place of business and can be directed to anyone's attention. DO NOT USE AN ADDRESS THAT IS NOT YET OCCUPIED. ALL FUTURE MAILINGS AND ANY CERTIFICATION REQUESTED ON THIS RENEWAL FORM WILL BE SENT TO THE ADDRESS IN BLOCK 1 OR AS CHANGED IN BLOCK 2. WE WILL NOT SEND CERTIFICATION TO ANY OTHER ADDRESS OR REDIRECT MAIL RETURNED TO THIS OFFICE. Block 3: Block 3 is designated for the Federal Employee Identification Number (FEI/ EIN Number) Block 4: Block 4 is preprinted with the county of the principal place of business. "MULTIPLE" may be preprinted if more than one county was reported when original registration was filed; change if necessary. Block 5: Block is preprinted with the date you filed in this office; if blank enter the correct file date, if known. Block 6: Should you desire a certificate of status certificate of status, please check the box in block 6 and include an additional $10.00 with the filing fee. The certificate of status will be sent to address in block 1 or in block 2, if changed. Block 7: Block 7 contains the Fictitious Names owner(s), their addresses document number and Federal Employer Identification Number (FEI) if applicable. (Due to space limitations only four owners are printed.) If there are additional owners, please list them on an attached sheet or in block 8 as additions. Do not make any changes in block 7 unless deleting an owner. Owners listed that are not individuals must be registered and active with this office or provide documentation as to why they are not required to register. Examples would be Federally Charters Corporations of Legislatively created entities. NOTE: If the fictitious indicated in block 1 contains the word(s) "corporation" or "incorporated, or the abbreviation "corp." or "Inc.", the owner(s) must be a corporation registered or incorporated with this state. Block 8: Block 8 is for changes or additions to the owners in block 7. Changes must be typed or printed in ink and legible. Owners that are not individuals must be registered and active with this office or provide documentation as to why they are not required to register. Examples would be Federally Chartered Corporations or Legislatively created entities. NOTE: If the fictitious indicated in block 1 contains the word(s) "corporation" or "incorporated, or the abbreviation "corp." or "Inc.", the owner(s) must be a corporation registered or incorporated with this state. Block 9: This renewal must in block 9 with an original signature by at least one owner that is listed block 7, block 8 if a change, or on an attachment. If this Application for Renewal of Fictitious Name is not filed on or before December 31, 2017 the fictitious name will be canceled and removed from the records of the Department of State. This renewal application must be post-marked by December 31, 2017. After the Application for Renewal is filed, effectiveness of the fictitious name registration is continued until December 31, 2022. MAILING ADDRESS: Fictitious Name Renewal Division of Corporations Post Office Box 1300 Tallahassee, Florida 32302-1300 INTERNET ADDRESS www.sunbiz.org COURIER SERVICE ADDRESS: Division of Corporations Clifton Building 2661 Executive Center Circle Tallahassee, Florida 32301 Phone Number (850) 245-6059 Hearing/Voice Impaired may call (850) 245-6096 (TDD) CR4E003 (02/17) American LegalNet, Inc. www.FormsWorkFlow.com MAKE CHECK PAYABLE TO DEPARTMENT OF STATE FILING F E E $50.00 PLEASE READ ALL INSTRUCTIONS CAREFULLY BEFORE COMPLETING THE FORM. IF YOU NEED ASSISTANCE, PLEASE CALL (850) 245-6058. INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR RENEWAL Block 2. If the mailing address printed in block 1 is incorrect, enter the correct mailing addres