Fictitious Business Name Statement - 2014 (Page 2 of 3) in pdf

Fictitious Business Name Statement - 2014 Page 2

AFFIDAVIT OF IDENTITY – FICTITIOUS BUSINESS NAME STATEMENT

In accordance with Section 17913 of the California Business and Professions Code, the following identifying information is

required to file a Fictitious Business Name Statement.

Registrant Name

Name of Business

Registrant Address

Street Address

City

State

Zip Code

Registrant Signature

If the registrant is a corporation, a limited liability company, a limited partnership, or a limited liability partnership, the

county clerk will require evidence issued by the Secretary of State indicating the current existence and good standing of

that business entity.

FOR OFFICE USE ONLY: ***To be completed by Deputy County Clerk for in-person filings only***

ID #: _______________________ Exp. Date: ______________ Deputy Signature: _____________________________

***For Mail or Third Party Requests Only***

This certificate must be notarized by a Notary Public for all Mail and Third Party Submissions

A notary public or other officer completing this certificate verifies only the identity

of the individual who signed the document to which this certificate is attached, and

not the truthfulness, accuracy, or validity of that document.

STATE OF CALIFORNIA

)

) ss

County of

)

Subscribed and sworn to (or affirmed) before me on this ______day of ____________, 20___, by

_______________________, proved to me on the basis of satisfactory evidence to be the person(s) who appeared

before me.

________________________________________

(Seal)

Signature

01-2015

Fictitious Business Name Statement - 2014 Page 2