Certificate Of Conducting Business Under An Assumed Name for Individual BUSINESS CERTIFICATE Pursuant to General Business Law § 130, I hereby certify that I intend to or am conducting or transacting business in the State of New York within the County of Nassau under the name or designation of ________ __________________________________________________________________________________________ at________________________________________________________________________________________ __________________________________________________________________________________________ My full name is ________________________________________________________________________ and I reside at __________________________________________________________________________ _____________________________________________________________________________________ I further certify that I am the successor in interest to ____________________________________________ _____________________________________________________________________________________ the person(s) previously using the name(s) specified above to carry on or conduct or transact business . [Complete if applicable] I am not less than eighteen years of age [I am less than eighteen years of age, to wit: ________ years of age]. IN WITNESS WHEREOF, I have signed this certificate on the _______day of ______________________, __________. _______________________________________ [Signature] Acknowledgement in New York State (RPL § 309-a) STATE OF NEW YORK COUNTY OF ) ) SS.: ) On the ______ day of ________________________ in the year __________ before me, the undersigned, personally appeared ___________________________________________________________________________, personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity(ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the the individual(s) acted, executed the instrument. _____________________________________ Notary Public NCC Rev. 9/2013 ***Form Must Be Filled Out in Black Ink Only*** American LegalNet, Inc. www.FormsWorkFlow.com