Certificate Form Of Doing Business Under An Assumed Name (D/b/a)
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1Certificate of Doing Business Under an Assumed Name (D/B/A)
Montgomery County Clerk’s Office, 64 Broadway, Fonda, NY 12068
Helen A. Bartone, Montgomery County Clerk (518) 853-8111
PURSUANT TO SECTION 130 OF THE GENERAL BUSINESS LAW OF NEW YORK STATE
I hereby certify that I intend to conduct business in the State of New York within the County of
Montgomery under the business name of
_____________________________________________________________________________________
(Business Name)
______________________________________________________________________________________________________
(Business Address)
______________________________________________________________________________________________________
(City/Town, State, Zip Code)
I certify that my name is (print) ___________________________________________________________
I reside at ____________________________________________________________________________
(Address)
if less than eighteen,
I am eighteen years of age or older (or,
my age is _____ years).
IN WITNESS WHEREOF, I have signed this certificate on the _____ day of _________________, 20___
_______________________________
(Signature)
Acknowledgement in New York State (RPL § 309-a)
State of New York,
)
County of
) ss:
On this ______ day of _____________ 20___, before me, the undersigned, personally appeared
personally known to me or proved to be on basis of satisfactory evidence to be the individual(s) whose name(s) is
(are) subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her
capacity(ies), and that by his/her signature on the instrument, the individual or the person upon behalf of which the
individual acted, executed the instrument.
_______________________________
(Notary Public)
Instructions: Completed form, must be signed in the presence of a Notary Public. The form should be filed at the Montgomery County
Clerk’s Office, County Bldg., 64 Broadway, Fonda, NY 12068. The recording fee is $25.00 and a $7.00 charge for each certified copy.
Fees may be paid in cash, money order or check. Starter checks are not accepted. If mailing please send a SASE>
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