CERTIFICATE OF DOING BUSINESS UNDER ASSUMED NAME ("D/B/A") Dutchess County Clerk's Office, 22 Market Street, Poughkeepsie, NY 12601 Bradford H. Kendall, Dutchess County Clerk (845-486-2120) PURSUANT TO SECTION 130 OF THE GENERAL BUSINESS LAW OF NEW YORK STATE 1. I certify that my name is (print name)______________________________________________ 2. I am eighteen (18) years of age or older (or if less than eighteen my age is __________ years.) 3. I live at (street address) _________________________________________________________ NY in (city/town)_________________________, (state) __________________ (zip)___________ 4. I intend to do business in DUTCHESS COUNTY at the following address: (street address) ________________________________________________________________ NY in (city/town)_________________________, (state) __________________ (zip)___________ 5. I will do business under the name _________________________________________________ ______________________________________________________________________________ 6. (optional) I further certify that we are the successors in interest to _______________________ ______________________________________________________________________________ (the person or persons who formerly used this name to conduct or transact business.) My signature:___________________________________________________________________ STATE OF NEW YORK } COUNTY OF DUTCHESS } SS: On this _______day of_____________________, 20___, before me, the undersigned, personally appeared ______________________________________________________________________________________ _____________________________________________, personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity and that by his/her signatures on the instrument the individual, or the person upon behalf of which the individual acted executed the instrument. ____________________________________________________________ (Signature and office of individual taking acknowledgment-Notary Public) American LegalNet, Inc. www.FormsWorkFlow.com