ALL INFORMATION MUST BE COMPLETED BEFORE RECORDING CERTIFICATE OF ASSUMED BUSINESS NAME (DBA) For individuals, (sole proprietorships), Firms, Partnerships or Limited Liability Companies engaged in business under a name other than their own STATE OF INDIANA, COUNTY OF ST JOSEPH Name of Business: ____________________________________________________ Kind of Business: _____________________________________________________ Address of Business: __________________________________________________ Street, City, State and Zip Code Printed names & complete residence addresses of members of business: _________________________ at ________________________________________ _________________________ at ________________________________________ _________________________ at ________________________________________ _________________________ at ________________________________________ I hereby certify that I have personal knowledge of the facts stated above and that each of them are true. _________________________ ___________________________ _________________ Signature Printed Name Capacity of Signer Form prepared by: _________________________________________________ Print name This completed form must be filed in the office of the County Recorder of each county in which a place of business or office is located. ___________________________ Date of Document ____________________________________ Recorder's Signature & Seal