Fictitious Business Name Statement Form
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1REGISTRAR - RECORDER / COUNTY CLERK’s FILING STAMP
Mailing Address:
Name:
Address
City
Renewal Filing
First Filing
1
With Changes
FICTITIOUS BUSINESS NAME STATEMENT
THE FOLLOWING PERSON(S) IS (ARE) DOING BUSINESS AS:
(Attach additional pages if required)
3.
Fictitious Business Name(s)
2
1
Articles of incorporation or Organization Number (if applicable)
Al #/ON
2
Street Address & City of Principal Place of Business in California (P .O. Box alone not acceptable)
Zip Code
3
Full name of Registrant
(if corporation - incorporated in what state)
4
Residence Street Address
City
State
Zip Code
Full name of Registrant
(if corporation - incorporated in what state)
4A
Residence Street Address
City
State
Zip Code
Full name of Registrant
(if corporation - incorporated in what state)
4B
Residence Street Address
City
State
Zip Code
( ) an individual
( ) a general partnership
( ) joint venture
( ) a business trust
This Business is
5
( ) co-partners
( ) husband and wife
( ) a corporation
( ) a limited partnership
conducted by:
(check one only)
( ) an unincorporated association other than a partnership
( ) a limited liability company
Type of Business:
6
Examples: Auto Repairing, Beauty Salon, Landscaping
( ) The registrant commenced to transact business under the fictitious business name or names listed on (Date):
7
( ) Registrant has not yet begun to transact business under the fictitious business name or names listed herein.
If registrant is not a corporation/ limited liability, sign below:
If Business is a corporation/limited liability co.:
8
8A
SIGNATURE
TYPE OR PRINT NAME
CORPORATION / LIMITED LIABILITY CO.
SIGNATURE
TYPE OR PRINT NAME
SIGNATURE
SIGNATURE
TYPE OR PRINT NAME
TITLE
SIGNATURE
TYPE OR PRINT NAME
TYPE OR PRINT OFFICERS NAME AND TITLE
This statement was filed with the County Clerk of
LOS ANGELES
County on date indicated by file stamp above.
NOTICE - THIS FICTITIOUS NAME STATEMENT EXPIRES FIVE YEARS FROM DATE IT WAS FILED IN THE OFFICE OF THE
COUNTY CLERK. A NEW FICTITIOUS BUSINESS NAME STATEMENT MUST BE FILED PRIOR TO THAT DATE. The filing of this
statement does not of itself authorize the use in this state of a fictitious business name in violation of the rights of another under federal,
state, or common law (See Section 14400 et seq., Business and Professions Code)
REGISTRAR - RECORDER/COUNTY CLERK
THIS FORM SHOULD BE TYPED
FILING FEE: $10.00 for 1 FBN and 2 registrants
BUSINESS FILING AND REGISTRATION
OR PRINTED “LEGIBLY” IN BLACK INK
plus $2.00 for each additional FBN / registrant
P.O. BOX 53592, LOS ANGELES,CA 90053-0592
FORM # 76F286D-F029 (Rev. 8/94)
PH: (562) 462-2177
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