Office of the Minnesota Secretary of State Assumed Name | Certificate of Assumed Name Read the instructions before completing this form. Filing Fee: $50 for expedited service in-person and online filings, $30 if submitted by mail Note: An Annual Renewal is required to be filed once every calendar year, beginning in the calendar year following the original filing with the Secretary of State. The filing of an assumed name does not provide a user with exclusive rights to that name. The filing is required for consumer protection in order to enable consumers to be able to identify the true owner of a business. 1. List the exact assumed name under which the business is or will be conducted: (Required) Minnesota Statutes, Chapter 333 2. Principal Place of Business: (Required) Street Address (A PO Box by itself is not acceptable) City State Zip 3. List the name and complete street address of all persons conducting business under the above Assumed Name, OR if an entity, provide the legal corporate, LLC, or Limited Partnership name and registered office address: (Required) Note: A PO Box by itself is not acceptable. Attach additional sheet(s) if necessary. Name Name Name Street Street Street City City City State State State Zip Zip Zip 4. I, the undersigned, certify that I am signing this document as the person whose signature is required, or as agent of the person(s) whose signature would be required who has authorized me to sign this document on his/her behalf, or in both capacities. I further certify that I have completed all required fields, and that the information in this document is true and correct and in compliance with the applicable chapter of Minnesota Statutes. I understand that by signing this document I am subject to the penalties of perjury as set forth in Section 609.48 as if I had signed this document under oath. Signature (Only one nameholder or an authorized agent is required to sign) Print Name and Title Email Address for Official Notices Enter an email address to which the Secretary of State can forward official notices required by law and other notices Date Check here to have your email address excluded from requests for bulk data, to the extent allowed by Minnesota law. American LegalNet, Inc. www.FormsWorkFlow.com Office of the Minnesota Secretary of State Assumed Name | Certificate of Assumed Name Minnesota Statutes, Chapter 333 List a name and daytime phone number of a person who can be contacted about this form: Contact Name Phone Number Entities that own, lease, or have any financial interest in agricultural land or land capable of being farmed must register with the MN Dept. of Agriculture's Corporate Farm Program. Minnesota Business Snapshot To better serve Minnesotans, the Secretary of State's Office has created the "Minnesota Business Snapshot," a short and simple survey produced with the input of business owners, business organizations, non-profits, and researchers from across the state. These five questions will take less than three minutes to complete, and you may answer any or all of them. There is no penalty if you choose not to provide this information. However, the answers you do provide will create a useful pool of information for potential customers and inform the analysis of our quarterly "Minnesota Economic and Business Condition Reports". We do not independently verify the answers applicants provide. Again, this survey is voluntary and the answers are considered public data. Thank you. 1. (Select up to one) - How many Minnesota ­ based full time employees (or FTE equivalents) does this entity currently have? 6-50 51-200 201-500 Over 500 2. (Select all that apply) - Does the owner or a member of the ownership group of this entity self-identify as a member of any of the following communities? Woman Member of a community of color Veteran Member of a disability community Member of an immigrant community 3. (Select up to one) - Using NAICS codes below, please select the code that best describes this entity. If you believe this entity falls into more than one category, please select the category that generates the majority of the entity's revenue. Agriculture, Forestry, Fishing and Hunting (Code 11) Mining (Code 21) Utilities (Code 22) Construction (Code 23) Manufacturing (Codes 31-33) Wholesale Trade (Code 42) Retail Trade (Codes 44-45) Transportation and Warehousing (Codes 48-49) Information (Code 51) Finance and Insurance (Code 52) Real Estate Rental and Leasing (Code 53) Professional, Scientific, and Technical Services (Code 54) Management of Companies and Enterprises (Code 55) Administrative and Support and Waste Management and Remediation Services (Code 56) Educational Services (Code 61) Health Care and Social Assistance (Code 62) Arts, Entertainment, and Recreation (Code 71) Accommodation and Food Services (Code 72) Other Services (except Public Administration) (Code 81) Public Administration (Code 92) 0-5 American LegalNet, Inc. www.FormsWorkFlow.com Office of the Minnesota Secretary of State Assumed Name | Certificate of Assumed Name Minnesota Statutes, Chapter 333 4. (Select up to one) Is this entity a full time or part time endeavor for those primarily responsible for operating this entity? Full time Part time 5. (Select up to one) - If applicable, what were this entity's gross revenues for the past year? $0 - $10,000 $10,001 - $50,000 $50,001 - $250,000 $250,001 - $1M Over $1M AssumedNameRegistrationRev.9/26/2016 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS File your business document online by visiting our website at www.sos.state.mn.us. This form is intended merely as a guide for filing and is not intended to cover all situations. Retain the original signed copy of this document for your records and submit a legible photocopy for filing with the Office of the Secretary of State. State law requires that this Certificate of Assumed Name be filed and published prior to the conduct of any business. Licensing and regulatory boards as well as private vendors and banks often require proof of the filing of this Certificate before issuing licenses, permits or entering into business relationships with the business. WHO MUST FILE: 1. Any person conducting business under a name which is not their true full name (first and last name) must file. (Example: "John Smith Painting" need not file, however, "Smith Painting" would be required to file.) 2. A corporation, limited partnership or limited liability company conducting business un