Cc-1050 Certificate Of Assumed Or Fictitious Name Template Page 2

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STATEMENT OF PARTNERS
This is to certify that the below named persons intend to carry on business under an assumed or fictitious name as partners in the
[ ] City of [ ] County of
, and
...................................................................................................................................................................................................
that the following is a list of every person owning the GENERAL PARTNERSHIP set forth on the front of this certificate.
_________________________________________________
...........................................................................................................................
PRINTED NAME (LAST, FIRST, MIDDLE)
SIGNATURE
........................................................................................................................................................................................................................................................................
RESIDENCE ADDRESS
[ ] City [ ] County of
State/Commonwealth of
..............................................................................
...................................................................................
Subscribed and acknowledged before me this
day of
, 20
.
........................
..........................................................................................
...........................
by
..................................................................................................................................................................................................................................................................
NAME
TITLE
_________________________________________________
[ ] NOTARY PUBLIC [ ] CLERK/DEPUTY CLERK
My commission expires
Registration No.
...........................................................................
................................................................................
...........................................................................................................................
_____________________________________________________________
PRINTED NAME (LAST, FIRST, MIDDLE)
SIGNATURE
........................................................................................................................................................................................................................................................................
RESIDENCE ADDRESS
[ ] City [ ] County of
State/Commonwealth of
..............................................................................
...................................................................................
Subscribed and acknowledged before me this
day of
, 20
.
........................
..........................................................................................
...........................
by
..................................................................................................................................................................................................................................................................
NAME
TITLE
_________________________________________________
[ ] NOTARY PUBLIC [ ] CLERK/DEPUTY CLERK
My commission expires
Registration No.
...........................................................................
................................................................................
_________________________________________________
...........................................................................................................................
PRINTED NAME (LAST, FIRST, MIDDLE)
SIGNATURE
........................................................................................................................................................................................................................................................................
RESIDENCE ADDRESS
[ ] City [ ] County of
State/Commonwealth of
..............................................................................
...................................................................................
Subscribed and acknowledged before me this
day of
, 20
.
........................
..........................................................................................
...........................
by
..................................................................................................................................................................................................................................................................
NAME
TITLE
_________________________________________________
[ ] NOTARY PUBLIC [ ] CLERK/DEPUTY CLERK
My commission expires
Registration No.
...........................................................................
................................................................................
...........................................................................................................................
_____________________________________________________________
PRINTED NAME (LAST, FIRST, MIDDLE)
SIGNATURE
........................................................................................................................................................................................................................................................................
RESIDENCE ADDRESS
[ ] City [ ] County of
State/Commonwealth of
..............................................................................
...................................................................................
Subscribed and acknowledged before me this
day of
, 20
.
........................
..........................................................................................
...........................
by
..................................................................................................................................................................................................................................................................
NAME
TITLE
_________________________________________________
[ ] NOTARY PUBLIC [ ] CLERK/DEPUTY CLERK
My commission expires
Registration No.
...........................................................................
................................................................................
FORM CC-1050 (MASTER, PAGE TWO OF TWO) 05/08
VA. CODE § 59.1-69

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