CERTIFICATE OF ASSUMED OR FICTITIOUS NAME Commonwealth of Virginia This is to certify that the below named person, partnership, limited liability company or corporation intends to conduct or transact business under an assumed or fictitious name in the [ ] City [ ] County of ........................................................................ . 1. The ASSUMED OR FICTITIOUS NAME of business ............................................................................................................... 2. ....................................................................................................................................................................................................... The above business is owned by the following entity type: [ ] SOLE PROPRIETORSHIP (Complete A below) [ ] PARTNERSHIP (Complete B below) [ ] LIMITED LIABILITY COMPANY (Complete C below) [ ] CORPORATION (Complete C below). A. NAME OF OWNER .............................................................................................................................................................. RESIDENCE ADDRESS ...................................................................................................................................................... POST OFFICE ADDRESS ................................................................................................................................................... B. NAME OF PARTNERSHIP ................................................................................................................................................. OFFICE ADDRESS .............................................................................................................................................................. POST OFFICE ADDRESS ................................................................................................................................................... (1) Is this a general partnership? [ ] NO [ ] YES. If YES, complete the Statement of Partners on Page Two of Two. (2) Is this a domestic limited partnership? [ ] NO [ ] YES. If YES, a certified copy of this certificate must be filed with the State Corporation Commission. Va. Code § 59.1-70. (3) Is this a foreign limited partnership? [ ] NO [ ] YES. If YES, indicate the date of the certificate of registration to transact business in the Commonwealth of Virginia issued by the State Corporation Commission: .................................................. A certified copy of this certificate must be filed with the State Corporation Commission. Va. Code § 59.1-70. C. NAME OF [ ] CORPORATION [ ] LIMITED LIABILITY COMPANY ........................................................................ .............................................................................................................................................................................................. OFFICE ADDRESS ............................................................................................................................................................ POST OFFICE ADDRESS ................................................................................................................................................. (1) A corporation or limited liability company must file a certified copy of this certificate with the State Corporation Commission. Va. Code § 59.1-70. (2) Is this a foreign corporation or a foreign limited liability company? [ ] NO [ ] YES. If YES, indicate the date of the certificate of authority/registration to transact business in the Commonwealth of Virginia issued by the State Corporation Commission: .......................................... ACKNOWLEDGMENT I certify that the foregoing is true and correct to the best of my knowledge and belief. Sole Proprietorship ................................................................................. NAME OF OWNER Partnership SIGNATURE OF OWNER ..................................................................................... NAME OF GENERAL PARTNER Corporation ___________________________________________ ___________________________________________ SIGNATURE OF GENERAL PARTNER ..................................................................................... ___________________________________________ NAME OF PRESIDENT SIGNATURE OF PRESIDENT Limited Liability Company ..................................................................................... NAME OF MEMBER/MANAGER [ ] City [ ] County of .......................................................... ___________________________________________ SIGNATURE OF MEMBER/MANAGER State/Commonwealth of .................................................................. Subscribed and acknowledged before me , this ................. day of ........................................................................., 20 ..................... by ......................................................................................................................................................................................................... NAME TITLE ___________________________________________ [ ] CLERK/DEPUTY CLERK [ ] NOTARY PUBLIC My commission expires ....................................................... Registration No. ......................................................... CLERK’S OFFICE Filed in the Clerks’ Office of the ................................................................... Circuit Court on ......................................................... DATE ..................................................................................... , Clerk by _____________________________________, Deputy Clerk FORM CC-1050 (MASTER, PAGE ONE OF TWO) 05/08 VA. CODE § 59.1-69 American LegalNet, Inc. www.FormsWorkflow.com STATEMENT OF PARTNERS This is to certify that the below named persons intend to carry on business under an assumed or fictitious name as partners in the [ ] City of [ ] County of .............................................................................................................................................................., and that the following is a list of every person owning the GENERAL PARTNERSHIP set forth on the front of this certificate. ................................................................................................... _________________________________________________ PRINTED NAME (LAST, FIRST, MIDDLE) SIGNATURE ..................................................................................................................................................................................................................... RESIDENCE ADDRESS [ ] City [ ] County of ............................................................... State/Commonwealth of .................................................................. Subscribed and acknowledged before me this .................................................... day of ..........., 20 ........................................... by ................................................................................................................................................................................................................ NAME TITLE _________________________________________________ [ ] NOTARY PUBLIC [ ] CLERK/DEPUTY CLERK My commission expires ............................................................ Registration No. ................................................................. ................................................................................................... _________________________________________________ PRINTED NAME (LAST, FIRST, MIDDLE) SIGNATURE ..................................................................................................................................................................................................................... RESIDENCE ADDRESS [ ] City [ ] County of ............................................................... State/Commonwealth of .................................................................. Subscribed and acknowledged before me this ...................................................... day of ........., 20 ............................................ by ................................................................................................................................................................................................................ NAME TITLE _________________________________________________ [ ] NOTARY PUBLIC [ ] CLERK/DEPUTY CLERK My commission expires ............................................................ Registration No. ................................................................. ................................................................................................... _________________________________________________ PRINTED NAME (LAST, FIRST, MIDDLE) SIGNATURE ..................................................................................................................................................................................................................... RESIDENCE ADDRESS [ ] City [ ] County of ............................................................... State/Commonwealth of .................................................................. Subscribed and acknowledged before me this ...................................................... day of ........., 20 ............................................ by ................................................................................................................................................................................................................ NAME TITLE _________________________________________________ [ ] NOTARY PUBLIC [ ] CLERK/DEPUTY CLERK My commission expires ............................................................ Registration No. ................................................................. ................................................................................................... _________________________________________________ PRINTED NAME (LAST, FIRST, MIDDLE) SIGNATURE ..................................................................................................................................................................................................................... RESIDENCE ADDRESS [ ] City [ ] County of ............................................................... State/Commonwealth of .................................................................. Subscribed and acknowledged before me this ...................................................... day of ........., 20 ............................................ by ................................................................................................................................................................................................................ NAME TITLE _________________________________________________ [ ] NOTARY PUBLIC [ ] CLERK/DEPUTY CLERK My commission expires ............................................................ FORM CC-1050 (MASTER, PAGE TWO OF TWO) 05/08 VA. CODE § 59.1-69 Registration No. ................................................................. American LegalNet, Inc. www.FormsWorkflow.com