(2) BY MAIL
A copy of a valid, government issued identification may be submitted with your Fictitious Business Name Statement in
lieu of completing this section in front of a Notary Public.
TO B
E COMPLETED BY NOTARY PUBLIC
S
tate of California )
) ss.
County of )
Subscribed and sworn to (or affirmed) before me on this ______ day of _____________, 20___,
by _____________________________________________________, proved to me on the basis of satisfactory evidence
(Name of person appearing)
to be the person(s) who appeared before me, ___________________________________.
(Signature of Notary Public)
(Notary Seal)
(3) THIRD PARTY FILING
I, _
____________________________ declare under penalty of perjury under the laws of the State of California that I am
(Print Name of Registrant)
the registrant / authorized signer who has signed this Fictitious Business Name Statement and I am authorized to submit said
statement to the County Clerk’s Office for filing.
I
am authorizing _____________________________ as my Authorized Agent to submit this Fictitious Business Name
(P
rint Name of Agent)
Statement on my behalf.
I understand that if I willfully make a false statement on this affidavit, I may be guilty of a misdemeanor punishable by a fine
not to exceed one thousand dollars
($1,000.00).
I declare that all information is this statement is true and correct.
S
igned on this ________day of ______________, 20_____ _______________________________________________
(Registrant Signature)
(4) TO BE COMPLETED BY THE AUTHORIZED AGENT
Agent Name ______________________________________________________________________________________
(First Name) (Last Name)
Name of Business __________________________________________________________________________________
I
, _____________________________, declare under penalty of perjury under the laws of the State of California that I am
the authorized agent filing this Fictitious Business Name on behalf of the registrant.
Signed on this ________day of ______________, 20_____ _______________________________________________
(Authorized Agent Signature)
For Office Use ONLY:
Agent ID: □ Driver’s License □ Identification Card □ Passport □ Other _________________________
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which
this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
CC312 (Rev. 5/8/17) Page 2
