MAIL
N-O-T-I-C-E This Fictitious Business Name Statement expires on ____________________________ 20_______________.
Type of Identification Presented: Driver’s License Identification Card Other
Issued in the State of: ______________________________
I hereby certify that this copy is a correct copy of the original statement on file in my office.
Joseph E. Canciamilla, Contra Costa County Clerk By: _________________________________________________Deputy
Please print or type
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JOSEPH E. CANCIAMILLA
COUNTY CLERK RECORDER
555 Escobar St.
Martinez, CA 94553-0135
(925)335-7900
FICTITIOUS BUSINESS NAME STATEMENT
1.
Residence Address
City State Zip
If Corporation/LLC/LLP Print State of Incorporation / Organization
2.
Residence Address
City State Zip
If Corporation/LLC/LLP Print State of Incorporation / Organization
3.
Residence Address
City State Zip
If Corporation/LLC/LLP Print State of Incorporation / Organization
4.
Residence Address
City State Zip
If Corporation/LLC/LLP Print State of Incorporation / Organization
See reverse side
for instructions
$30.00...For First Business Name on Statement
$7.00…….For each additional Business Name on the same
statement and doing business at the same location
$7.00…….For each additional owner in excess of one owner
This business is conducted by: An Individual Married Couple A General Partnership Co Partners A Joint Venture
A Limited Partnership A Corporation A Trust Limited Liability Partnership A Limited Liability Co.
State or Local Registered Domestic Partners An Unincorporated Association other than a Partnership
For Office Use Only: Verification of Corp., LLP, LLC
The registrant commenced to transact business under the fictitious business name(s) listed above on _____________________________________________
Signature of Registrant___________________________________________________________________________________________________________
________________________________________________________________________________________________________________
Print Name of Person Signing. If Corporation or LLC also print title of officer.
Full Name Type / Print
Full Name Type / Print
Full Name Type / Print
Full Name Type / Print
If More Than 4 Registrants Attach Additional Sheet Showing Information
Print Fictitious Business Name(s) on Line Above
Street Address of Principal Place of Business Mailing Address, if different
City State Zip County City State Zip
Registrant(s)
Insert N/A if you haven’t started to transact business
I declare that all information in this statement is true and correct. A registrant who executes this statement knowing that such statement is false in whole / in part shall be guilty of a misdemeanor B&P 17930
New Renew
Print
Clear Form
Contra Costa
INSTRUCTIONS FOR COMPLETION OF STATEMENT
Business and Professions Code Section 17913:
* Where one asterisk appears in the form:
(a) Insert the fictitious business name or names
(b) Only those businesses operated at the same address and under the same ownership may be listed on one statement
** Where two asterisks appear in the form:
(a) If the registrant has a place of business in this state, insert the street address and county of his or her principal place of business in this
state
(b) If the registrant has no place of business in this state, insert the street address and county of his or her principal place of business outside
this state and file with the Clerk of Sacramento County (B&P 17915)
(c) Mail Box and Post Office Box Numbers are not acceptable as a business address when used alone without a street address
*** Where three asterisks appear in the form:
(a) If the registrant is an individual, insert his or her full name and residence address
(b) If the registrants are a married couple, insert the full name and residence address of both parties
(c) If the registrant is a general partnership, copartnership, joint venture, limited liability partnership, or unincorporated association other than a
partnership, insert the full name and residence address of each general partner
(d) If the registrant is a limited partnership, insert the full name and residence address of each general partner
(e) If the registrant is a limited liability company, insert the name and address of the limited liability company, as set out in its articles of
organization on file with the CA Secretary of State, and the state of organization
(f) If the registrant is a trust, insert the full name and residence address of each trustee
(g) If the registrant is a corporation, insert the name and address of the corporation, as set out in its articles of incorporation on file with the CA
Secretary of State, and the state of incorporation
(h) If the registrants are state or local registered domestic partners, insert the full name and residence address of each domestic partner
**** Where four asterisks appear in the form:
(a) Check whichever of the terms listed on the front of the form best describes the nature of the business
***** Where five asterisks appear in the form:
(a) Insert the date on which the registrant first commenced to transact business under the fictitious business name or names listed, if already
transacting business under that name or names
(b) Insert N/A if you have not yet commenced to transact business under the fictitious business name or names listed
Business and Professions Code Section 17914
The statement shall be signed as follows:
(a) If the registrant is an individual, by the individual
(b) If the registrants are a married couple, by either party
(c) If the registrant is a general partnership, limited partnership, limited liability partnership, copartnership, joint venture or unincorporated
association other than a partnership, by a general partner
(d) If the registrant is a limited liability company, by a manager or officer
(e) If the registrant is a trust, by a trustee
(f) If the registrant is a corporation, by an officer
(g) If the registrant is a state or local registered domestic partnership, by one of the domestic partners
Business and Professions Code Section 17915
The fictitious business name statement shall be filed with the clerk of the county in which the registrant has his or her principal place of business in this
state, or if the registrant has no place of business in this state, with the Clerk of Sacramento County. Nothing in this chapter shall preclude a person from
filing a fictitious business name statement in a county other than that where the principal place of business is located, as long as the requirements of this
subdivision are also met.
Business and Professions Code Section 17917
Publication for Original, New Filings (renewal with change in facts from previous filing), or Refile
(a) Within 30 days after a fictitious business names statement has been filed, the registrant shall cause it to be published in a newspaper of
general circulation in the county where the fictitious business name statement was filed, or if there is no such newspaper in that county, in a
newspaper of general circulation in an adjoining county. If the registrant does not have a place of business in this state, the notice shall be
published in a newspaper of general circulation in Sacramento County. The publication must be once a week for four successive weeks
and an affidavit of publication must be filed with the county clerk where the fictitious business name statement was filed within 30 days after
the completion of the publication
(b) If a refilling is required because the prior statement has expired, the refilling need not be published, unless there has been a change in the
information required in the expired statement, provided the refilling is filed within 40 days of the date the statement expired.
Business and Professions Code Section 17922
Abandonment of Fictitious Business Name
(a) Upon ceasing to transact business in this state under a fictitious business name that was filed in the previous five years, a person who has
filed a fictitious business name statement shall file a statement of abandonment of use of fictitious business name. The statement shall be
executed and published in the same manner as a fictitious business names statement and shall be filed with the county clerk of the county
in which the person has filed his or her fictitious business name statement
Business and Professions Code Section 17930
Any person who executes, files, or publishes any statement under this chapter, knowing that such statement is false, in whole or in part shall be guilty of a
misdemeanor and upon conviction thereof shall be punished by a fine not to exceed one thousand dollars ($1,000)
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