______________________________________________________________________________________________________________ Prepared By: (Name, Address, City, State, Zip, Phone #) ______________________________________________________________________________________________________________ Return Document To: (Name & Complete Address if different from Preparer Info) Trade Name Verified statements of person or co-partnership conducting a business under a trade name or assumed name. (Chapter 547, Code of Iowa) STATE OF IOWA, POLK COUNTY, Names of Person(s) Owning or Having Interest in the Business: _____________________________________________________________________________________IA____________________ Name Address City Zip _____________________________________________________________________________________IA____________________ Name Address City Zip _____________________________________________________________________________________IA____________________ Name Address City *CHECK ONE BOX PER FORM* I (we) in compliance with the provisions of Chapter 547, Code of Iowa, hereby establish or amend Trade Name as follows: Establish Trade Name ____________________________________________________________________________________________________ Name of Business ____________________________________________________________________________________________________________________________ Complete Business Address (Required) Dissolve Trade Name ____________________________________________________________________________________________________ Original Book _______________________ Page _________________ Add/Withdrawal name(s) of Partner(s) _______________________________________________________________________________________ Name of Business_______________________________________________ Original Book _______________________ Page _________________ Change of Address _______________________________________________________________________________________________________ Business / Home (Circle One) Complete Address Name of Business_______________________________________________ Original Book _______________________ Page _________________ Zip And that there is no one except those mentioned in the foregoing list who owns or has any interest in the above named business. I (we) further certify that a corrected statement will be filed in the future each time there may be any change in ownership, as provided by Section 547.2, Code of Iowa. _____________________________________X _________________________________ Date Signed: ________________ Printed Name Signature _____________________________________X _________________________________ Date Signed: ________________ Printed Name Signature _____________________________________X _________________________________ Date Signed: ________________ Printed Name Signature Subscribed in my presence and sworn to before me by the said _________________________________________________________ this ______ day of ____________________ ____________. X __________________________________________ Notary Public in and for ________________ COUNTY, _________________. American LegalNet, Inc. www.FormsWorkFlow.com