Nevada County Fictitous Business Name Abandoment Statement

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

This space for use of County Clerk

Fill in this form on your screen; then print, sign and submit FOUR COPIES. File # ______________________________

Filing Fee: $24.00

STATEMENT OF ABANDONMENT OF USE OF FICTITIOUS BUSINESS NAME The following person (persons) have abandoned the use of the fictitious business name: __________________________________________ at ____________________________________ Street Address of principal place of business

The fictitious business name referred to above was filed in: ________________ on ______________ (Name of County)

#1

#2

(Full Name Type/Print)

(Full Name Type/Print)

________________________________________________________________________

________________________________________________________________________ (Address)

(Date)

________________________________________________________________________

________________________________________________________________________ (Address)

________________________________________________________________________

City

State

ZIP

________________________________________________________________________

City

________________________________________________________________________

(If Corporation or LLC -- Print State of Incorporation/Organization)

(If Corporation or LLC -- Print State of Incorporation/Organization)

#4

(Full Name Type/Print)

(Full Name Type/Print)

________________________________________________________________________ (Address)

ZIP

________________________________________________________________________

#3

________________________________________________________________________

State

________________________________________________________________________

________________________________________________________________________ (Address)

________________________________________________________________________

City

State

ZIP

________________________________________________________________________

City

________________________________________________________________________

(If Corporation or LLC -- Print State of Incorporation/Organization)

State

ZIP

________________________________________________________________________

(If Corporation or LLC -- Print State of Incorporation/Organization)

This business was conducted by: (Check one of the following)

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

SIGNATURE OF REGISTRANT:

______________________________________________

_______________________________________________________________________________ (Print name of person signing. If corporation, also print corporate title of officer. If LLC, also print title of officer or manager.)

This statement was filed with the County Clerk of Nevada County on the date indicated by the filed stamp in the upper right corner.

I HEREBY CERTIFY THAT THIS COPY IS A CORRECT COPY OF THE ORIGINAL STATEMENT ON FILE IN MY OFFICE.

Gregory J. Diaz, County Clerk

By: _____________________________________, Deputy FBN abandonment--WEB Revised 5/19/2008