Form Mllc-5 - Statement Of Intention To Do Business Under An Assumed Or Fictitious Name - Maine Secretary Of State Page 2

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DATED __________________________
MANAGER(S)/MEMBER(S)*
___________________________________________________
___________________________________________________
(signature)
(type or print name and capacity)
For Manager(s)/Member(s) which are Entities
Name of Entity ________________________________________________________________________________________________
By ________________________________________________
___________________________________________________
(authorized signature)
(type or print name and capacity)
*Certificate MUST be signed by
(1) at least one manager OR
(2) at least one member if the limited liability company is managed by the members OR
(3) any duly authorized person.
The execution of this certificate constitutes an oath or affirmation under the penalties of false swearing under
Title 17-A, section
453.
Please remit your payment made payable to the Maine Secretary of State.
SUBMIT COMPLETED FORMS TO: CORPORATE EXAMINING SECTION, SECRETARY OF STATE,
101 STATE HOUSE STATION, AUGUSTA, ME 04333-0101
FORM NO. MLLC-5 (2 of 2) Rev. 7-1-2003
TEL. (207) 624-7740

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