Fillable FICTITIOUS NAME WILL EXPIRE ON 12/31 of the (Florida Division of Corporations)

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FICTITIOUS NAME WILL EXPIRE ON 12/31 of the (Florida Division of Corporations)

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FLORIDA DEPARTMENT OF STATE
DIVISION OF CORPORATIONS
FILE TO RENEW NOW:
FICTITIOUS NAME WILL EXPIRE ON 12/31 of the 5th Year
APPLICATION FOR RENEWAL OF FICTITIOUS NAME
SECRETARY OF STATE
REGISTRATION #
1. Name and Mailing Address
If above mailing address is incorrect in any way, line through incorrect information and enter correction in Block 2.
2. Mailing Address change if applicable:
Suite, Apt. #, etc.
City State Zip Code
3. County of Principal
Place of Business
4. Date Registered
5. Certificate of Status Desired
❏
$10 Additional Fee Required
AN OWNER THAT IS A CORPORATION, LIMITED PARTNERSHIP OR OTHER BUSINESS ENTITY
MUST BE REGISTERED AND ACTIVE WITH THIS OFFICE.
6. CURRENT OWNER (S) 7. ADDITIONS / CHANGES TO OWNERS
Signature of Owner Date
Signature of Owner Date
DOCUMENT # ❏
DELETE
DOCUMENT # ❏
Change
❏
Addition
FEI # FEI #
NAME NAME
STREET ADDRESS STREET ADDRESS
CITY- ST- ZIP CITY- ST- ZIP
DOCUMENT # ❏
DELETE
DOCUMENT # ❏
Change
❏
Addition
FEI # FEI #
NAME NAME
STREET ADDRESS STREET ADDRESS
CITY- ST- ZIP CITY- ST- ZIP
DOCUMENT # ❏
DELETE
DOCUMENT # ❏
Change
❏
Addition
FEI # FEI #
NAME NAME
STREET ADDRESS STREET ADDRESS
CITY- ST- ZIP CITY- ST- ZIP
DOCUMENT # ❏
DELETE
DOCUMENT # ❏
Change
❏
Addition
FEI # FEI #
NAME NAME
STREET ADDRESS STREET ADDRESS
CITY- ST- ZIP CITY- ST- ZIP
8. I (we) the undersigned, being the sole (all the) party(ies) owning interest in the above fictitious name, certify that the information indicated on this form is
true and accurate. I (we) understand that the signature(s) below shall have the same legal effect as if made under oath. I further certify that the names of
individuals listed on this form do not qualify for an exemption contained in section 119, Florida Statutes. (At least one signature required)
❏
CHECK HERE IF MAKING CHANGES
CR4E0003 (10/20)
FILING FEE $50.00
MAKE CHECK PAYABLE TO DEPARTMENT OF STATE
PLEASE READ ALL INSTRUCTIONS CAREFULLY BEFORE COMPLETING
THE FORM. IF YOU NEED ASSISTANCE, PLEASE CALL (850) 245-6058.
INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR RENEWAL
Block 1. Block is preprinted with the fictitious name, the registration number, and mailing address of the business as it was originally
registered with this office. The name of the business cannot be changed on the statement of renewal. A cancellation/reregistration
must be filed. Please call (850) 245-6058 for the appropriate form.
Block 2. If the mailing address printed in block 1 is incorrect, enter the correct mailing address in block 2. This address does NOT have
to be the principal place of business and can be directed to anyone’s attention. DO NOT USE AN ADDRESS THAT IS NOT YET
OCCUPIED. ALL FUTURE MAILINGS AND ANY CERTIFICATION REQUESTED ON THIS RENEWAL FORM WILL BE SENT TO THE
ADDRESS IN BLOCK 1 OR AS CHANGED IN BLOCK 2. WE WILL NOT SEND CERTIFICATION TO ANY OTHER ADDRESS OR
REDIRECT MAIL RETURNED TO THIS OFFICE.
Block 3. Block is preprinted with the county of the principal place of business. “MULTIPLE” may be preprinted if more than one county
was reported when original registration was filed; change if necessary.
Block 4. Block is preprinted with the date filed in this office; if blank enter the correct file date, if known.
Block 5. Should you desire a certificate of status, please check the box in block 5 and include an additional $10.00 with the filing fee. The
certificate of status will be sent to address in block 1 or in block 2, if changed.
Block 6. Block 6 contains the Fictitious Name owner(s), their addresses, document number and Federal Employer Identification Number
(FEI) if applicable. (Due to space limitations only four owners are printed.) If there are additional owners, please list them on an
attached sheet or in block 7 as additions. Do not make any changes in block 6 unless deleting an owner. Owners listed that are
not individuals must be registered and active with this office or provide documentation as to why they are not required to
register. Examples would be Federally Chartered Corporations or Legislatively created entities. NOTE: If the fictitious name
indicated in block 1 contains the word(s) ”corporation” or “incorporated”, or the abbreviation “corp.” or “Inc.”, the owner(s)
must
be a corporation registered or incorporated with this state.
Block 7. Block 7 is for changes or additions to the owners in block 6. Changes must be typed or printed in ink and legible. Owners that
are not individuals must be registered and active with this office or provide documentation as to why they are not required to
register. Examples would be Federally Chartered Corporations or Legislatively created entities. NOTE: If the fictitious name
indicated in block 1 contains the word(s) “corporation” or “incorporated”, or the abbreviation “corp.” or “Inc.”, the owner(s)
must
be a corporation registered or incorporated with this state.
Block 8. This renewal must be signed in block 8 with an original signature by at least one owner that is listed in block 6, block 7 if a
change, or on an attachment.
Phone Number: (850) 245-6058
Hearing/Voice Impaired may call (850) 245-6096 (TDD)
If this Application for Renewal of Fictitious Name is not filed on or before December 31, 2008,
the fictitious name will be cancelled and removed from the records of the Department of State.
This renewal application must be post-marked by December 31, 2008.
After the Application for Renewal is filed, the effectiveness of the fictitious name registration is
continued until December 31, 2013.
Courier Service Address:
Division of Corporations
Clifton Building
2661 Executive Center Circle
Tallahassee, Florida 32301
Internet Address:
www.sunbiz.org
MAILING ADDRESS:
Fictitious Name Renewal
Division of Corporations
Post Office Box 1300
Tallahassee, Florida 32302-1300
Other Correspondence:
Division of Corporations
P.O.Box 6327
Tallahassee, Florida 32314
CR4E0003 (1/08)
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FICTITIOUS NAME WILL EXPIRE ON 1231 of the (Florida Division of Corporations)

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Completed 24 July 2021

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