MINNESOTA SECRETARY OF STATE CERTIFICATE OF ASSUMED NAME RENEWAL Read the instructions before completing this form. The following information pertains to a certificate of Assumed Name that was filed with the Office of the Secretary of State on the date listed in item #2. This certificate will expire if this renewal form is not completed and returned to our office by the expiration date listed in item #3. The filing fee for the Renewal is $25 which will renew the registration for 10 years. Please remember that this document must be signed by the current nameholder or an authorized agent. Attach add'l sheets for nameholders if necessary. Assumed Name # CURRENT INFORMATION ON FILE: 1. Assumed Name INFORMATION YOU WISH TO CHANGE: Assumed Name 2. Date of Original Filing 3. Current Expiration Date 10 Year Extension 4. Business Address Business address (must be a full street address)˜ 5. Nameholder(s) and Address(es) Nameholder(s) and Address(es) (If any changes are being made to the nameholder(s) and/or their address(es), please be sure to list ALL of the current nameholders and their full street addresses in this box.) 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. 6. Signature ___________________________________________________________________ ____________________ (Signature of current nameholder or authorized agent) Date 7. Name and telephone number of a contact person ___________________________________(____)________________ AssumedNameRenewalRev.08-01-10 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS Retain the original signed copy of this document for your records and submit a legible photocopy for filing with the Secretary of State. 1. Review the information currently on file with the Secretary of State's office. This information is found on the left side of the form. 2. If the information on file with our office is current, the nameholder must sign the document and submit the renewal along with the $25 filing fee. 3. If the information on the left side of the form is no longer current, please fill in the current information in the box to the right of the item that you are changing. 4. If any changes are made to item #5, please remember to fill in the name and full street address of all persons conducting business under this assumed name. Note: If the business owner is a corporation or other business entity you must give the legal business name and the legal registered office address or principal place of business, whatever is applicable. Attach additional sheets for nameholders if necessary. 5. The form must be signed by one of the most current nameholder(s), or authorized agent (The signing party must indicate on the document that they are acting as the agent of the person(s) whose signature would be required and that they have been authorized to sign on behalf of that person(s). 6. We will notify you when your assumed name renewal has been accepted. If the right side of the form has been filled in, you must publish the changes in the legal notices of a qualified legal newspaper for two consecutive issues, in the county in which the business has its principal or registered office. The newspaper will then send back to you an affidavit of publication, with the newspaper ad attached. The affidavit does not need to be sent to our office. Failure to publish the changes may render them invalid. 7. List the name and daytime telephone number of a person who can be contacted about the form. 8. The penalty for doing business without filing this renewal is a $250.00 fee payable to any opposing party in any legal contest. 9. Filing Fee is $25.00 Payable to the MN Secretary of State. FILE IN-PERSON OR MAIL TO: Minnesota Secretary of State - Business Services Retirement Systems of Minnesota Building 60 Empire Drive, Suite 100 St Paul, MN 55103 (Staffed 8:00 - 4:00, Monday - Friday, excluding holidays) To obtain a copy of a form you can go to our web site at www.sos.state.mn.us , or contact us between 9:00am to 4:00pm, Monday through Friday at (651) 296-2803 or toll free 1-877-551-6767. All of the information on this form is public. Minnesota law requires certain information to be provided for this type of filing. If that information is not included, your document may be returned unfiled. This document can be made available in alternative formats, such as large print, Braille or audio tape, by calling (651)296-2803/voice. For a TTY/TTD (deaf and hard of hearing) communication, contact the Minnesota Relay Service at 1-800-627-3529 and ask them to place a call to (651)296-2803. The Secretary of State's Office does not discriminate on the basis of race, creed, color, sex, sexual orientation, national origin, age, marital status, disability, religion, reliance on public assistance or political opinions or affiliations in employment or the provision of service. American LegalNet, Inc. www.FormsWorkFlow.com