Minnesota Secretary Of State Request For Cancellation Of Assumed Name Form - 2010
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MINNESOTA SECRETARY OF STATE
Once your form is completed,
be sure to select "Print" at the
REQUEST FOR CANCELLATION
bottom of the screen to
OF ASSUMED NAME
capture your data entry for
printing. After printing, sign
and send applicable fees as
required.Note: Selecting
"Reset" will clear all data entry
from this page. To print a
READ THE INSTRUCTIONS BEFORE COMPLETING THIS FORM
blank form, go to File->Print.
_____________________________________________________________________
Assumed Name
_____________________________________________________________________
File Number
_____________________________________________________________________
Filing Date
I, the undersigned, certify that I am signing this document as the person whose signature is required, or as agent
of the person(s) whose signature would be required who has authorized me to sign this document on his/her behalf,
or in both capacities. I further certify that I have completed all required fields, and that the information in this document
is true and correct and in compliance with the applicable chapter of Minnesota Statutes. I understand that by signing
this document I am subject to the penalties of perjury as set forth in Section 609.48 as if I had signed this document
under oath.
Signature of Partner(s) or an Authorized Agent: ________________________________________________
Print Name: ________________________________________________
________________________________________________
________________________________________________
_____________________________________________________________________
Name & phone number of contact person
INSTRUCTIONS
Retain the original signed copy of this document for your records and submit a legible photocopy for filing with the Secretary
of State. All of the information on this form is public and required in order to process this filing. Failure to provide the requested i
processing this filing.
All current nameholders or an Authorized Agent (The signing party must indicate on the document that they are acting as the
agent of the person(s) whose signature would be required and that they have been authorized to sign on behalf of that
person(s).) must sign this cancellation form. Please include attachments if necessary.
There is no fee for cancelling an Assumed Name.
Print
FILE IN-PERSON OR MAIL TO:
Minnesota Secretary of State - Business Services
Retirement Systems of Minnesota Building
Reset
60 Empire Drive, Suite 100
St Paul, MN 55103
(Staffed 8:00 - 4:00, Monday - Friday, excluding holidays)
To obtain a copy of a form you can go to our web site at
, or contact us between 9:00am to
4:00pm, Monday through Friday at (651) 296-2803 or toll free 1-877-551-6767.
AssumedName
Rev.
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