Cc-1050 Certificate Of Assumed Or Fictitious Name Template

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CERTIFICATE OF ASSUMED OR FICTITIOUS NAME

Commonwealth of Virginia

This is to certify that the below named person, partnership, limited liability company or corporation intends to conduct or

transact business under an assumed or fictitious name in the [ ] City [ ] County of ........................................................................ .

1. The ASSUMED OR FICTITIOUS NAME of business

.......................................................................................................................................................................................................

2. The above business is owned by the following entity type:

[ ] SOLE PROPRIETORSHIP (Complete A below) [ ] PARTNERSHIP (Complete B below)

[ ] LIMITED LIABILITY COMPANY (Complete C below) [ ] CORPORATION (Complete C below).

A. NAME OF OWNER ..............................................................................................................................................................

RESIDENCE ADDRESS ......................................................................................................................................................

POST OFFICE ADDRESS ...................................................................................................................................................

B. NAME OF PARTNERSHIP .................................................................................................................................................

OFFICE ADDRESS ..............................................................................................................................................................

POST OFFICE ADDRESS ...................................................................................................................................................

(1) Is this a general partnership? [ ] NO [ ] YES. If YES, complete the Statement of Partners on Page Two of Two.

(2) Is this a domestic limited partnership? [ ] NO [ ] YES. If YES, a certified copy of this certificate must be filed

with the State Corporation Commission. Va. Code § 59.1-70.

(3) Is this a foreign limited partnership? [ ] NO [ ] YES. If YES, indicate the date of the certificate of registration to

transact business in the Commonwealth of Virginia issued by the State Corporation

Commission: ..................................................

A certified copy of this certificate must be filed with the State Corporation Commission. Va. Code § 59.1-70.

C. NAME OF [ ] CORPORATION [ ] LIMITED LIABILITY COMPANY

..............................................................................................................................................................................................

OFFICE ADDRESS ............................................................................................................................................................

POST OFFICE ADDRESS .................................................................................................................................................

(1) A corporation or limited liability company must file a certified copy of this certificate with the State Corporation

Commission. Va. Code § 59.1-70.

(2) Is this a foreign corporation or a foreign limited liability company? [ ] NO [ ] YES. If YES, indicate the date of

the certificate of authority/registration to transact business in the Commonwealth of Virginia issued by the State

Corporation Commission: ..........................................

ACKNOWLEDGMENT

I certify that the foregoing is true and correct to the best of my knowledge and belief.

Sole Proprietorship .................................................................................

___________________________________________

NAME OF OWNER

SIGNATURE OF OWNER

Partnership

.....................................................................................

___________________________________________

NAME OF GENERAL PARTNER

SIGNATURE OF GENERAL PARTNER

Corporation

.....................................................................................

___________________________________________

NAME OF PRESIDENT

SIGNATURE OF PRESIDENT

Limited Liability

Company

.....................................................................................

___________________________________________

NAME OF MEMBER/MANAGER

SIGNATURE OF MEMBER/MANAGER

[ ] City [ ] County of ..........................................................

State/Commonwealth of ..................................................................

Subscribed and acknowledged before me , this ................. day of ........................................................................., 20 .....................

by .........................................................................................................................................................................................................

NAME

TITLE

___________________________________________

[ ] CLERK/DEPUTY CLERK [ ] NOTARY PUBLIC

My commission expires .......................................................

Registration No. .........................................................

CLERK’S OFFICE

Filed in the Clerks’ Office of the ................................................................... Circuit Court on .........................................................

DATE

..................................................................................... , Clerk by _____________________________________, Deputy Clerk

FORM CC-1050 (MASTER, PAGE ONE OF TWO) 05/08

VA. CODE § 59.1-69