Form 76f286d-F029 - Fictitious Business Name Statement
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1REGISTRAR - RECORDER / COUNTY CLERK's FILING STAMP
A
Name:
Address:
City:
1
FICTITIOUS BUSINESS NAME STATEMENT
THE FOLLOWING PERSON(S) IS (ARE) DOING BUSINESS AS: (Attach additional pages if required)
Fictitious Business Name(s)
3.
1.
2
Articles of Incorporation or Organization Number (if applicable)
2.
Al #/ON
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
This Business is
(
) an individual
(
) a general partnership
(
) joint venture
(
) a business trust
5
conducted by:
(
) co-partners
(
) husband and wife
(
) a corporation
(
) a limited partnership
(check one only)
(
) an unincorporated association other than a partnership
(
) a limited liability company
(
) The registrant commenced to transact business under the fictitious business name or names listed on (Date):
6
(
) Registrant has not yet begun to transact business under the fictitious business name or names listed herein.
7
I declare that all information in this statement is true and correct.
(A registrant who declares as true information which he or she knows to be false is guilty of a crime.)
Signature of Registrant(s)
If Registrant IS a CORPORATION, sign below
8
8A
Signature
type/print name
Corporation or Company Name
Signature
type/print name
Signature
Signature
type/print name
Title
Signature
type/print name
Type or Print Name
LOS ANGELES
This statement was filed with the County Clerk of
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 14411 et seq., Business and
Professions Code)
THIS FORM SHOULD BE TYPED
REGISTRAR - RECORDER/COUNTY CLERK
FILING FEE: $10.00 for 1 FBN and 2 registrants
OR PRINTED "LEGIBLY" IN BLACK INK.
BUSINESS FILING AND REGISTRATION
P.O. BOX 53592, LOS ANGELES, CA 90053-0592
plus $2.00 for each additional FBN/registrant.
FORM # 76F286D-F029 (Rev. 1/02)
PH: (562) 462-2177
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