NYS Department of State
Division of Corporations, State Records and Uniform Commercial Code
One Commerce Plaza, 99 Washington Ave,
Certificate of Assumed Name
Albany, NY 12231-0001
Pursuant to General Business Law§130
1. REAL NAME OF ENTITY:
1a. FICTITIOUS NAME, IF ANY, OF FOREIGN ENTITY (Not Assumed Name):
2. FORMED OR AUTHORIZED UNDER THE FOLLOWING NEW YORK LAW (Check one):
Business Corporation Law
Limited Liability Company Law
Religious Corporations Law
Education Law
Not-for-Profit Corporation Law
Revised Limited Partnership Act
Other (specify law):
3. ASSUMED NAME:
4. PRINCIPAL PLACE OF BUSINESS IN NEW YORK STATE (MUST INCLUDE NUMBER AND STREET). IF NONE, CHECK THIS BOX
AND PROVIDE OUT-OF-
STATE ADDRESS:
ALL COUNTIES
(or check applicable county(ies) below)
5. COUNTY(IES) IN WHICH ENTITY DOES OR INTENDS TO DO BUSINESS:
Delaware
Orleans
Schuyler
Albany
Chautauqua
Genesee
Lewis
New York
Richmond
Tompkins
Wyoming
Oswego
Allegany
Rockland
Seneca
Ulster
Chemung
Dutchess
Greene
Livingston
Niagara
Yates
Bronx
Erie
Oneida
Otsego
Steuben
Warren
Chenango
Hamilton
Madison
St. Lawrence
Broome
Clinton
Essex
Herkimer
Monroe
Washington
Onondaga
Putnam
Saratoga
Suffolk
Cattaraugus
Columbia
Franklin
Jefferson
Montgomery
Ontario
Queens
Sullivan
Wayne
Schenectady
Rensselaer
Cayuga
Cortland
Fulton
Kings
Nassau
Orange
Schoharie
Tioga
Westchester
6. ADDRESS OF EACH LOCATION, INCLUDING NUMBER AND STREET, IF ANY, OF EACH PLACE WHERE THE ENTITY CARRIES ON, CONDUCTS OR TRANSACTS
BUSINESS IN NEW YORK STATE. Use page 2 if needed. The address(es) must be a number and street, city state and zip code. The address(es) reflected in paragraph 6
must be within the county(ies) indicated in paragraph 5. If none, check the box:
No New York State Business Location
Name of Signer:
Signature:
Capacity of Signer (Check one):
Officer of the Corporation
General Partner of the Limited Partnership
Member of the Limited Liability Company
Manager of the Limited Liability Company
Authorized Person
Filer:
Name:
Mailing Address:
City, State and Zip Code:
NOTE: This form was prepared by the New York State Department of State. You are not required to use this form. All documents should be prepared under the guidance of
an attorney. The certificate must be submitted with a $25 fee. For corporations, the Department of State also collects the following, additional, county clerk fees for each
county in which a corporation does or intends to do business as indicated in paragraph 5: $100 for each county within New York City (Bronx, Kings, New York, Queens and
Richmond) and $25 for each county outside New York City. All checks over $500 must be certified.
(For office use only)
DOS-1338-f-l (Rev. 05/13)
Page 1 of 2