Consent To The Use Of A Name - Minnesota Secretary Of State, Affidavit For The Registration Of A Name - Minnesota Secretary Of State
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2For your convenience, this form has
been designed to be completed
online. You must have Acrobat
Reader 5.0 or above to use this new
feature. Once your form is
STATE OF MINNESOTA
completed, be sure to select "Print"
at the bottom of the screen to
SECRETARY OF STATE
capture your data entry for printing.
CONSENT TO THE USE OF A NAME
After printing, sign and send
applicable fees as required.Note:
Selecting "Reset" will clear all data
entry from this page. To print a blank
form, go to File->Print.
PLEASE TYPE OR PRINT LEGIBLY IN BLACK INK.
Please complete this side if this office has a name already on file that is similar to the name you wish to register. If you are
unable to locate the holder of the name already on file, see the reverse side of this form. Submit this form to the office
along with the original filing or amendment you wish to record.
1. Name You Wish to Register: _________________________________________________________________________
2. Name Already on File:______________________________________________________________________________
Address: ___________________________________________________________________________________________
(street)
(city)
(state)
(zip)
PLEASE HAVE THIS PORTION COMPLETED BY THE HOLDER OF THE NAME ALREADY ON FILE:
I grant consent to register the name listed on line 1 to: ________________________________________________________
(list name of person or entity registering new name)
located at ___________________________________________________________________________________________
(street)
(city)
(state)
(zip)
(Check one)
____ unconditionally.
____ with the following conditions:* __________________________________________________________
______________________________________________________________________________________
*NOTE: Conditions must be privately enforced.
I certify that I am authorized to sign this consent and I further certify that I understand that by signing this consent I am
subject to the penalties of perjury as set forth in section 609.48 as if I had signed this consent under oath.
Signed: ____________________________________________________________
Position: __________________________Daytime Phone:_____________________
INSTRUCTIONS
1. Complete one form for each name already on file.
2. Filing fee: $35.00 per form, payable to the MN Secretary of State.
Print only this page
FILE IN-PERSON OR MAIL TO:
Minnesota Secretary of State - Business Services
Reset
Retirement Systems of Minnesota Building
60 Empire Drive, Suite 100
St Paul, MN 55103
(Staffed 8:00 - 4:00, Monday - Friday, excluding holidays)
All of the information on this form is public. Minnesota law requires certain information to be provided for this type of filing. If
that information is not included, your document may be returned unfiled. This document can be made available in alternative
formats, such as large print, Braille or audio tape, by calling (651)296-2803/voice. For a TTY/TTD (deaf and hard of hearing)
communication, contact the Minnesota Relay Service at 1-800-627-3529 and ask them to place a call to (651)296-2803. The
Secretary of State's Office does not discriminate on the basis of race, creed, color, sex, sexual orientation, national origin,
age, marital status, disability, religion, reliance on public assistance or political opinions or affiliations in employment or the
provision of service.
bus6 Consent Rev. 05-07
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