Nevada County Clerk-recorder Fictitious Business Name Statement

Print Form FICTITIOUS BUSINESS NAME STATEMENT NEVADA COUNTY CLERK-RECORDER Eric Rood Administrative Center 950 Maidu Ave. Nevada City, CA 95959 (530) 265-1221

FILE # ___________________________ TYPE OF FILING (Check one)

o Original o New Filing (Change(s) in facts from previous filing)

This space for use of County Clerk

FILING FEE

o Refile

$24.00 - One Business Name and one Owner $2.00 - For each additional Partner/Owner in excess of one Partner/Owner $5.00 - For each additional Business Name filed on the same statement and doing business at the same location

(No change(s) in facts from previous filing) Previous File # ________________

Fill in this form on your screen, then print, sign and submit FOUR COPIES

The following person (persons) is (are) doing business as:

* ______________________________________________________________________________ ** ___________________________________________ _________________________________ Print Fictitious Business Name[s] on the line above.

`

Street Address of principal place of business

Mailing address if different

___________________________________________ _________________________________ City

State

ZIP

COUNTY

City

State

ZIP

BEFORE COMPLETING THIS SECTION, CLICK HERE to download instructions

*** REGISTERED OWNERS: #1:

#2:

________________________________________________________________________ Residence Address if not incorporated; State of Incorporation if incorporated.

________________________________________________________________________ Residence Address if not incorporated; State of Incorporation if incorporated.

________________________________________________________________________ City and ZIP

________________________________________________________________________ City and ZIP

#3:

#4:

________________________________________________________________________ Residence Address if not incorporated; State of Incorporation if incorporated.

________________________________________________________________________ Residence Address if not incorporated; State of Incorporation if incorporated.

________________________________________________________________________ City and ZIP

________________________________________________________________________ City and ZIP

________________________________________________________________________ Full Name

________________________________________________________________________ Full Name

________________________________________________________________________ Full Name

________________________________________________________________________ Full Name

(If more than 4 Registrants, attach additional sheet showing Owner information.)

****

This business is conducted by:

*** **

The registrant commenced to transact business under the fictitious business name[s] listed above on this date: _______________

o an Individual o a General Partnership o a Limited Partnership    o a Limited Liability Company o an Unincorprated Association other than a Partnership o a Corporation o a Trust o Copartners o Husband and Wife o a Joint Venture   o State or Local Registered Domestic Partners o a Limited Liability Partnership I declare that all information in this statement is true and correct. (A registrant who declares as true information which he or she knows to be false is guilty of a crime.)

SIGNATURE OF REGISTRANT:

______________________________________________

______________________________________________ (Enter name of person signing and, if a Corporate Officer, also state Title.)

THIS STATEMENT WAS FILED WITH THE COUNTY CLERK OF NEVADA COUNTY ON DATE INDICATED ABOVE.

CERTIFICATION

I hereby certify that the foregoing is a full, true and correct copy of the original on file in this office. Gregory J. Diaz, Clerk-Recorder

By: _____________________________________, Deputy

Fill in this form on your screen, then print, sign and submit FOUR COPIES. FBN statement--Online Revised 1/1/2008