Office of the Minnesota Secretary of State Abandoned Name Affidavit Read the instructions before completing this form. Filing Fee: $55 for expedited service in-person, $35 if submitted by mail 1. Name you wish to register: (Required) 2. Name already on file: (Required) 3. Address of business already on file: (Required) Street Address City State Zip Code I hereby certify that I have the right to register the desired name because I have fulfilled ALL of the requirements of Minnesota Statutes listed below: A. I have determined that the entity or person holding the conflicting name has not filed any document under that name with the Office of the Secretary of State of Minnesota during the preceding three years. B. I have sent written notice to this entity or person at the last registered office or business address as listed with the Secretary of State, and that notice was sent by certified mail and has been returned as undeliverable. C. After diligent inquiry, I have been unable to find any telephone listing for that entity or person in the county in which that registered office or business address is located; and D. I have no personal knowledge that the entity or business is currently engaged in business in this state. 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 of Authorized Person or Authorized Agent Print Name and Position 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. List a name and daytime phone number of a person who can be contacted about this form: Contact Name Phone Number American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS Please complete this form if you are unable to locate the holder of a name already on file to obtain Consent to Use of Name in order to register your name. Submit this form along with the original filing or amendment you wish to record. Complete one form for each name already on file. 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. 1. List the business name you wish to register. (Required) 2. List the business name on file with this office that is in conflict with the name you are filing. (Required) 3. List the address of the business on file with this office. (Required) 4. Signature of authorized person or 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).) Email Address for Official Notices. This email address may be used to send annual renewal reminders and other important notices that may require action or response. Check the box if you wish to have your email address excluded from requests for bulk data, to the extent allowed by Minnesota law. List a name and daytime telephone number of a person who can be contacted about this form. Filing Fee: $55 for expedited service in-person, $35 if submitted by mail Payable to the MN Secretary of State Please submit all items together and mail to the address below: 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 a.m. � 4 p.m., Monday - Friday, excluding holidays) Phone Lines: (9 a.m. - 4 p.m., M-F) Metro Area 651-296-2803; Greater MN 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. AbandonedNameAffidavitRev.8/19/2016 American LegalNet, Inc. www.FormsWorkFlow.com