Fillable Certificate of Assumed Name (New York State)

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Certificate of Assumed Name (New York State)

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Page 1 of 2
DOS-1338-f-l (Rev. 10/13)
Certificate of Assumed Name
Pursuant to General Business Law§130
NYS Department of State
Division of Corporations, State Records and Uniform Commercial Code
One Commerce Plaza, 99 Washington Ave,
Albany, NY 12231-0001
www.dos.ny.gov
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):
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:
5. COUNTY(IES) IN WHICH ENTITY DOES OR INTENDS TO DO BUSINESS:
Albany
Allegany
Bronx
Broome
Cattaraugus
Cayuga
Chautauqua
Chemung
Chenango
Clinton
Columbia
Cortland
Delaware
Dutchess
Erie
Essex
Franklin
Fulton
Genesee
Greene
Hamilton
Herkimer
Jefferson
Kings
Lewis
Livingston
Madison
Monroe
Montgomery
Nassau
New York
Niagara
Oneida
Onondaga
Ontario
Orange
Orleans
Oswego
Otsego
Putnam
Queens
Rensselaer
Richmond
Rockland
St. Lawrence
Saratoga
Schenectady
Schoharie
Schuyler
Seneca
Steuben
Suffolk
Sullivan
Tioga
Tompkins
Ulster
Warren
Washington
Wayne
Westchester
Wyoming
Yates
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:
Business Corporation Law
Education Law
Religious Corporations Law
Other (specify law):
Limited Liability Company Law
Not-for-Profit Corporation Law
Revised Limited Partnership Act
ALL COUNTIES (or check applicable county(ies) below)
Name of Signer:
Signature:
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.
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
No New York State Business Location
Page 2 of 2
DOS-1338-f-l (Rev. 10/13)
6. ADDRESS OF EACH LOCATION, INCLUDING NUMBER AND STREET, IF ANY, OF EACH PLACE WHERE THE ENTITY CARRIES ON OR CONDUCTS OR
TRANSACTS BUSINESS IN NEW YORK STATE: (Continued)
Page 2 (If needed)
(
For office use only
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Certificate of Assumed Name (New York State)

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Completed 22 January 2021

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