Statement Of Trade Name Of A Non Reporting Entity (Page 2 of 2) in pdf

5. The trade name under which such non-reporting entity transacts business or conducts activities or

contemplates transacting business or conducting activities in this state is

______________________________________________________________________________________.

6. A brief description of the kind of business transacted or activities conducted or contemplated to be

transacted or conducted in this state under such trade name is

______________________________________________________________________________________.

(If the following statement applies, adopt the statement by marking the box and include an attachment.)

This document contains additional information as provided by law.

(Caution: Leave blank if the document does not have a delayed effective date. Stating a delayed effective date has

significant legal consequences. Read instructions before entering a date.)

(If the following statement applies, adopt the statement by entering a date and, if applicable, time using the required format.)

The delayed effective date and, if applicable, time of this document are ____________________________.

(mm/dd/yyyy hour:minute am/pm)

Notice:

Causing this document to be delivered to the Secretary of State for filing shall constitute the affirmation or

acknowledgment of each individual causing such delivery, under penalties of perjury, that such document is

such individual's act and deed, or that such individual in good faith believes such document is the act and deed

of the person on whose behalf such individual is causing such document to be delivered for filing, taken in

conformity with the requirements of part 3 of article 90 of title 7, C.R.S. and, if applicable, the constituent

documents and the organic statutes, and that such individual in good faith believes the facts stated in such

document are true and such document complies with the requirements of that Part, the constituent documents,

and the organic statutes.

This perjury notice applies to each individual who causes this document to be delivered to the Secretary of

State, whether or not such individual is identified in this document as one who has caused it to be delivered.

9. The true name and mailing address of the individual causing this document to be delivered for filing are

____________________ ______________ ______________ _____

(Last)

(First)

(Middle)

(Suffix)

______________________________________________________

(Street number and name or Post Office Box information)

______________________________________________________

__________________________

____________________

(City)

(State)

(Postal/Zip Code)

_______________________ ______________.

(Province – if applicable)

(Country – if not US)

(If the following statement applies, adopt the statement by marking the box and include an attachment.)

This document contains the true name and mailing address of one or more additional individuals

causing the document to be delivered for filing.

Disclaimer:

This form/cover sheet, and any related instructions, are not intended to provide legal, business or tax advice,

and are furnished without representation or warranty. While this form/cover sheet is believed to satisfy

minimum legal requirements as of its revision date, compliance with applicable law, as the same may be

amended from time to time, remains the responsibility of the user of this form/cover sheet. Questions should

be addressed to the user’s legal, business or tax advisor(s).

TRDNM_NRE

Page 2 of 2

Rev. 1/01/2008

Statement Of Trade Name Of A Non Reporting Entity Page 2

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