Typeoffiling:(Checkone)
First‐timeapplicant
Renewalwithchanges
Renewal–Nochanges
Previousfile#:
_______________________________
ExpirationDate:_________________
SantaCruzCountyClerk
701OceanSt.,Room310,SantaCruz,CA95060
831‐454‐2060/831‐454‐2445(FAX)/TTY:711
www.sccoclerk.com
FictitiousBusinessNameStatement
FilingFee
$45forfirstbusinessnameandowneronstatement
$7foreachadditionalbusinessnamefiledonthesame
statementandconductingbusinessatthesamelocation
$7foreachadditionalowner
TobecompletedbyDeputyCountyClerk.
Ifapplyinginperson,youmustshowID.
IDchecked________
Applicationreceivedbymail:_________
Paymentmaybemadebycheckorcashonly.
Checkpaymentsshouldbemadepayableto:
SantaCruzCountyClerk
Applicationmaybesubmittedinpersonorby
mailtotheaddressabove.
*______________________________________________________________________________________
PrintFictitiousBusinessName(s)(Usea/toseparateadditionalnamesorattachanadditionalsheetifapplyingforseveralbusinessnames)
**_________________________________________|___________________________________________
Streetaddressofprincipalplaceofbusiness Mailingaddress(ifdifferentfromstreetaddress)
___________________________________________|___________________________________________
City  State Zip County City State Zip
***RegisteredOwner(s):
1.
____________________________________ 2. ______________________________________

FullLegalName(IfCorporationorLLC–PrintNameofCorp/Org) FullLegalName(IfCorporationorLLC–PrintNameofCorp/Org)
____________________________________ ______________________________________
ResidenceAddress(EntityAddressforCorporation/LLC) ResidenceAddress(EntityAddressforCorporation/LLC)
____________________________________ ______________________________________
City State Zip City State Zip
Iftherearemorethantwo(2)registrants,pleaseattachadditionalsheetshowingownerinformation.
**** Thisbusinessisconductedby:(Checkone)
anIndividual
aMarriedCouple
RegisteredDomesticPartners
aGeneralPartnership
aTrust
Copartners
JointVenture
anUnincorporatedAssociation
otherthanaPartnership
aLimitedPartnership
1
aLimitedLiabilityCompany
1
aLimitedLiabilityPartnership
1
aCorporation
1

1-must file appropriate documentation. (Articles of Incorporation, Certificate of Organization, or the Statement of Information filed with CA SOS)
*****
Theregistrantstartedtotransactbusinessunderthefictitiousbusinessname/slistedaboveon:MM/DD/CCYY
Theregistranthasnotyetbeguntotransactbusinessunderthefictitiousbusinessname(s)listedherein.
Ideclarethatallinformationinthisstatementistrueandcorrect.
(AregistrantwhodeclaresastrueanymaterialmatterpursuanttoSection17913oftheB&Pcodethattheregistrantknowstobefalseisguiltyofa
misdemeanorpunishablebyafinenottoexceedonethousanddollars($1,000).)
SignatureofRegisteredOwner:
__________________________________________________________________
ForCorporation/LLC:PrintNameofOfficer/Member:______________________________________________________________________________
ForCorporation/LLC:PrintTitleofOfficer/Member:
__________________________________________________________________________________________
(CEO,CFO,Pres.,VicePres.,Sec.,Treas.areacceptabletitles.ManagingMemberisanacceptabletitleforanLLC.)
1
‐ForCorporation/LLC:SubmitacopyofyourArticlesofIncorporationorCertificateofOrganizationwiththisapplication(newfilings&renewals).Please
includeyourStatementofInformation.Itliststhenamesoftheofficersofthecorporation/managingmembersofthelimitedliabilitycompany.
InaccordancewiththeSubdivision(a)ofSection17920,afictitiousbusinessnamestatementgenerallyexpiresattheendoffiveyearsfromthedateonwhichitwasfiledintheOfficeoftheCounty
Clerk,exceptasprovidedinSubdivision(b)ofSection17920,whereitexpires40daysafteranychangeinthefactssetforthinthestatementpursuanttoSection17913,otherthanachangeinthe
residenceaddressofaregisteredowner.Anewfictitiousbusinessnamestatementmustbefiledbeforetheexpiration.
Thefilingofthisstatementdoesnotofitselfauthorizetheuseinthisstateofafictitiousbusinessnameinviolationoftherightsofanotherunderfederal,stateorcommonlaw(seeSection14411ET
SEQ.,BusinessandProfessionCode).
Iherebycertifythatthiscopyisacorrectcopy
oftheoriginalstatementonfileinmyoffice.
Gail L. Pellerin, Santa Cruz County Clerk By:_____________________________________________, Deputy Clerk
click to sign
signature
click to edit
HowtocompletetheFBN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addressand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tothemarriage.
(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ofthe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) Entercurrentorpastdateonwhichtheregistrantfirstcommencedtotransactbusinessunderthefictitiousbusinessname(s)listed,ifalready
transactingbusinessunderthatname(s)
(b) Ifyouhavenotyetcommencedtotransactbusinessunderthefictitiousbusinessname(s)listedenterN/A.
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oneofthepartiestothemarriage.
(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name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refilingisrequiredbecausethepriorstatementhasexpired,therefilingneednotbepublished,unlesstherehasbeenachangeinthe
informationrequiredintheexpiredstatement,providedtherefiling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name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wholeor
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).
BusinessandProfessionsCodeSection17928
Uponprepaymentofafee,theCountyClerkmayfurnishtoanypersonwhosorequests,summariesorcompilationsoffilings.Foralistofwhopurchasesthis
datapleasecontacttheCountyclerk.
CLK115Rev.7/2019