Fictitious Business Name Statement

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San Bernardino County
Recorder - Clerk
222 W. Hospitality Lane, 1
Floor
st
San Bernardino CA 92415-0022
855 REC-CLRK
BUSINESS OWNER IS RESPONSIBLE TO
DETERMINE IF PUBLICATION IS REQUIRED
(BPC 17917)
FICTITIOUS BUSINESS NAME STATEMENT
NEW FILING - this is a:
Renewal
First Filing
New Amended Filing
Date of
ABANDONMENT:
County of Current Filing
Current Filing
File No.
Fees: $55.00 Includes one registrant (please make check payable to “County Clerk”)
$10.00 Each additional registrant
$10.00 Each additional FBN name filed on same statement and operating at same location
$ 4.00 Mail processing fee
Please TYPE or PRINT legibly and firmly in DARK ink (no alterations). See reverse side for filing and publishing instructions. The determination whether or not
publication is required by law is ENTIRELY THE RESPONSIBILITY OF THE REGISTRANT. Neither the County Clerk nor his deputies are permitted by law to give legal advice
THE FOLLOWING PERSON(S) IS (ARE) DOING BUSINESS AS:
and/or assistance.
LIST FICTITIOUS BUSINESS NAME BELOW (as shown in the Articles of Inc./Org./Reg.)
Franchise No. (if applicable)
County of Principal Place of Business
1
Street Address of Principal Place of Business (P.O. Box or PMB address NOT acceptable)
City
State
Zip Code
2
Mailing Address (Optional)
City
Zip Code
State
(1) Name of Individual Registrant (First name)
(Middle initial only) (Last name)
(1) Name of corporation or limited liability company as shown in the Articles of Inc./Org./Reg.
State of Inc./Org. / Reg. Inc./Org./Reg. No.
Residence Street Address/Corporation or LLC Street Address
City
State
Zip Code
3
(2) Name of Individual Registrant (First name)
(Middle initial only) (Last name)
(2) Name of corporation or limited liability company as shown in the Articles of Inc./Org./Reg.
State of Inc./Org. / Reg. Inc./Org./Reg. No.
Residence Street Address/Corporation or LLC Street Address
City
State
Zip Code
List any additional names on additional form
(CHECK ONE ONLY) This business is/was conducted by:
4
A Married Couple
An Individual
A Limited Liability Partnership
State or Local Registered Domestic Partners
A General Partnership
An Unincorporated Assoc. Other Than a Partnership
A Joint Venture
A Limited Partnership
A Corporation
A Limited Liability Company
Copartners
A Trust
Registrant commenced to transact business under the fictitious business name or names listed above on (do not enter a future date).
5
(If registrant has not yet commenced to transact business, insert the statement "Not applicable").
Month, Day, Year
BY SIGNING, I DECLARE THAT ALL INFORMATION IN THIS STATEMENT IS TRUE AND CORRECT.
A registrant who declares as true any material matter
pursuant to Section 17913 of the Business and Professions Code that the registrant knows to be false is guilty of a misdemeanor punishable by a fine not to exceed one
thousand dollars ($1,000).)
I am also aware that all information on this statement becomes Public Record upon filing pursuant to the California Public Records Act
(Government Code Sections 6250-6277). It is also my responsibility to determine if publication is required (BPC 17917).
6
Printed Name of
Signature:
Person Signing:
Printed Title of
Person Signing:
Date:
NOTICE--IN ACCORDANCE WITH SUBDIVISION (a) OF SECTION 17920, A FICTITIOUS NAME STATEMENT GENERALLY EXPIRES AT THE END OF FIVE YEARS FROM THE
DATE ON WHICH IT WAS FILED IN THE OFFICE OF THE COUNTY CLERK, EXCEPT, AS PROVIDED IN SUBDIVISION (b) OF SECTION 17920, WHERE IT EXPIRES 40 DAYS
AFTER ANY CHANGE IN THE FACTS SET FORTH IN THE STATEMENT PURSUANT TO SECTION 17913 OTHER THAN A CHANGE IN THE RESIDENCE ADDRESS OF A
REGISTERED OWNER. A NEW FICTITIOUS BUSINESS NAME STATEMENT MUST BE FILED BEFORE THE EXPIRATION. THE FILING OF THIS STATEMENT DOES NOT OF
ITSELF AUTHORIZE THE USE IN THIS STATE OF A FICTITIOUS BUSINESS NAME IN VIOLATION OF THE RIGHTS OF ANOTHER UNDER FEDERAL, STATE, OR COMMON
LAW (SEE SECTION 14411 ET SEQ., BUSINESS AND PROFESSIONS CODE).
Rev. 04/04/16

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