Withdrawal Notice Of An Assumed Name Form - Jefferson County Clerk

For Clerk’s Use Only

CAROLYN L. GUIDRY, JEFFERSON COUNTY CLERK

P.O. BOX 1151

BEAUMONT, TEXAS 77704-1151

409-835-8475

WITHDRAWAL NOTICE OF AN ASSUMED NAME

NOTICE: THIS CERTIFICATE OF WITHDRAWAL PROPERLY EXECUTED IS TO BE FILED IMMEDIATELY WITH THE COUNTY CLERK, AS

PROVIDED BY LAW

FILING FEE: $23.00 WITH ONE OWNER (ADD .50¢ FOR EACH ADDITIONAL OWNER)

NAME OF BUSINESS BEING ABANDONED

____________________________________________________________________________________________________________

PRINT OR TYPE NAME OF BUSINESS

BUSINESS ADDRESS: _______________________________________________________________________________________

CITY: ________________________________________ STATE: _______________________ ZIP CODE: __________________

1. DATE ORIGINAL ASSUMED NAME WAS FILED IN THIS OFFICE: ___________________________________________

2. NAME OTHER FILING OFFICES, IF ANY, WHERE YOU FILED THE SAME ASSUMED NAME: _________________

____________________________________________________________________________________________________________

Each of the undersigned has this day withdrawn from or disposed of his interest in the above mentioned business and is no longer

connected with the same, and will not be responsible for debts contracted by said business after the filing of this Withdrawal Notice as

prescribed by law.

(Please print or type)

NAME: ______________________________________________ SIGNATURE: _________________________________________

Residence Address: __________________________________________________________________________________________

NAME: ______________________________________________ SIGNATURE: _________________________________________

Residence Address: __________________________________________________________________________________________

NAME: ______________________________________________ SIGNATURE: _________________________________________

Residence Address: __________________________________________________________________________________________

THE STATE OF TEXAS

COUNTY OF JEFFERSON

BEFORE ME, THE UNDERSIGNED AUTHORITY, on this day personally appeared __________________________________________

________________________________________________________________________________________________________________________

known to me to be the person(s) whose name(s) is/are subscribed to the foregoing instrument and acknowledged to me that (s)he executed the same

for the purpose and consideration therein expressed.

GIVEN UNDER MY HAND AND SEAL OF OFFICE, on _______________.

Notary

________________________________________________________

Seal:

Signature of Notary Public/Deputy County Clerk

Printed Name of

Deputy County Clerk: _____________________________________

For Clerk’s Use Only

Withdrawal Notice Of An Assumed Name Form - Jefferson County Clerk - Texas