Statement Of Abandonment Of Use Of A Business Or Professional Name For Unincorporated Business Or Profession Form

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STATEMENT OF ABANDONMENT OF USE OF A BUSINESS OR PROFESSIONAL NAME
FOR UNINCORPORATED BUSINESS OR PROFESSION
1.
The Assumed Business or Professional Name being abandoned is:
___________________________________________________________________________________________________________
2.
The date on which the Assumed Name Certificate was filed:__________________________________________________________
3.
The Registrants name(s) and residence or office address as shown on the Assumed Name Certificate:
Name: _____________________________________
Name: __________________________________________
Address: ___________________________________
Address: ________________________________________
City State Zip: _______________________________
City State Zip: ____________________________________
Name: _____________________________________
Name: __________________________________________
Address: ___________________________________
Address: ________________________________________
City State Zip: _______________________________
City State Zip: ____________________________________
To certify which, witness my/our hand(s) this the _________ day of ___________________________, 20 ________.
By signing this application, the applicant(s) acknowledge understanding of and compliance with the statutes cited below
Name: ____________________________________________
Signature: _________________________________________________
Residence Address: _________________________________
City State Zip: ______________________________________
Printed Name/Title:__________________________________________
Name: ____________________________________________
Signature: _________________________________________________
Residence Address: _________________________________
City State Zip: ______________________________________
Printed Name/Title:__________________________________________
Name: ____________________________________________
Signature: _________________________________________________
Residence Address: _________________________________
City State Zip: ______________________________________
Printed Name/Title:__________________________________________
Name: ____________________________________________
Signature: _________________________________________________
Residence Address: _________________________________
City State Zip: ______________________________________
Printed Name/Title:__________________________________________
WARNING: INTENTIONALLY PROVIDING FALSE OR FRAUDULENT INFORMATION ON THIS APPLICATION IS A VIOLATION OF THE LAW
AND MAY RESULT IN IMPRISONMENT OF NOT MORE THAN 5 YEARS AND/OR FINE OF UP TO $ 10,000. (Texas Business and
Commerce Code, Chapter 71, Sec. 71.203; Texas Penal Code, Chapter 12 and Chapter 37, Sec. 37.10)
THE STATE OF ______________________
COUNTY OF ________________________
Before me on this day personally appeared _________________________________________________________________________
___________________________________________________________________________________________________________, known to me
or proved to me through ___________________________________ to be the person(s) whose name(s) is/are subscribed to the foregoing
instrument and acknowledged to me that he/she/they executed the same for the purposes and consideration therein expressed.
GIVEN UNDER MY HAND AND SEAL OF OFFICE, ON ________________________________________________, 20 ___________.
______________________________________________
Notary Public/Printed Name
SPACE BELOW RESERVED FOR RECORDING PURPOSES

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