NYS Department of State Division of Corporations, State Records and UCC One Commerce Plaza, 99 Washington Ave, Albany, NY 12231-0001 Certificate of Assumed Name Pursuant to General Business Law, §130 www.dos.state.ny.us 1. NAME OF ENTITY 1a. FOREIGN ENTITIES ONLY. If applicable, the fictitious name the entity agreed to use in New York State is: 2. NEW YORK LAW FORMED OR AUTHORIZED UNDER (CHECK ONE): Business Corporation Law Limited Liability Company Law Education Law Not-for-Profit Corporation Law Insurance Law Revised Limited Partnership Act Other (specify law): 3. ASSUMED NAME 4. PRINCIPAL PLACE OF BUSINESS IN NEW YORK STATE (MUST BE NUMBER AND STREET. IF NONE, INSERT OUT-OF-STATE ADDRESS) 5. COUNTIES IN WHICH BUSINESS WILL BE CONDUCTED UNDER ASSUMED NAME ALL COUNTIES (if not, circle county[ies] below) Albany Clinton Genesee Monroe Orleans Saratoga Tompkins Allegany Columbia Greene Montgomery Oswego Schenectady Ulster Bronx Cortland Hamilton Nassau Otsego Schoharie Warren Broome Delaware Herkimer New York Putnam Schuyler Washington Cattaraugus Dutchess Jefferson Niagara Queens Seneca Wayne Cayuga Erie Kings Oneida Rensselaer Steuben Westchester Chautauqua Essex Lewis Onondaga Richmond Suffolk Wyoming Chemung Franklin Livingston Ontario Rockland Sullivan Yates Chenango Fulton Madison Orange St. Lawrence Tioga 6. INSERT THE ADDRESS OF EACH LOCATION WHERE BUSINESS WILL BE CARRIED ON OR TRANSACTED UNDER THE ASSUMED NAME. Use a continuous sheet, if needed. (The address must be set forth in terms of a number and street, city, state and zip code. Please note that the address(es) reflected in paragraph 6 must be within the county(ies) circled in paragraph 5. If the entity does not have a specific location where it will conduct business under the assumed name please check the statement below.) No New York State Business Location DOS-1338 (Rev. 4/08) -1American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS FOR SIGNATURE: If corporation, by an officer; if limited partnership, by a general partner; if limited liability company, by a member or manager or by an authorized person or attorney-in-fact for such corporation, limited partnership, or limited liability company. If the certificate is signed by an attorney-in-fact, include the name and title of the person for whom the attorney-in-fact is acting. (Example, John Smith, attorney-in-fact for Robert Johnson, president.) Name of Signer Signature Title of Signer CERTIFICATE OF ASSUMED NAME OF (Insert Entity Name) Pursuant to §130, General Business Law FILER’S NAME AND MAILING ADDRESS NOTE: This form was prepared by the New York State Department of State. You are not required to use this form. You may draft your own form or use forms available at legal stationery stores. The Department of State recommends that all documents be prepared under the guidance of an attorney. The certificate must be submitted with a $25 fee. The Department of State also collects the following, additional, county clerk fees for each county in which a corporation does or transacts business: $100 for each county within New York City (Bronx, Kings, New York, Queens and Richmond) and $25 for each county outside New York City. All checks over $500 must be certified. (For office use only) -2American LegalNet, Inc. www.FormsWorkflow.com