Read all instructions prior to completing. This form may be submitted online at
Fee: $70
Check one: Amendment (§ 312) Withdrawal (§ 313) Cancellation (§ 313)
In compliance with the requirements of 54 Pa.C.S. Ch.3 (relating to fictitious names), the undersigned entity or
entities, desiring to amend, withdraw or cancel from a fictitious name registration, hereby state(s) that:
1. The fictitious name is:
2. The address of the principal place of business, including number and street, if any, is:
Number and street City State Zip County
3. The last preceding filing with respect to this fictitious name was made in the Department on
4. A brief statement of the character or nature of the business or other activity to be carried on under or
through the fictitious name is:
Return document by mail to:
City State Zip Code
Return document by email to: ________________________________
Fictitious Name
Amendment, Withdrawal, Cancellation
DSCB:54-312/313 (rev. 7/2015)
5. Check one or more of the following, as appropriate:
The fictitious name has been changed to:
The principal place of business set forth in paragraph 2 has been changed to (PO Box alone not
Number and street City State Zip County
The following party(ies) has (have) been added to the registration and their signature(s) appear(s) at
the end of this application.
Name Number and street City State Zip
The following party(ies) has (have) withdrawn from the business and their signature(s) appear(s) at
the end of this application.
Name Number and street City State Zip
The fictitious name registration is cancelled.
6. Check box for Application for Amendment Only:
This amendment, without reference to any other filing sets forth all information with respect to the
fictitious name which would be required in an original filing under the Fictitious Names Act.
7. Optional-See Instruction F: This application has been executed by an agent heretofore designated for
that purpose in a prior filing in this registration.
IN TESTIMONY WHEREOF, the undersigned has (have) caused this Application for Amendment,
Withdrawal or Cancellation of/from Fictitious Name to be executed this
day of , .
Adding party(ies) signature(s) Withdrawing party(ies) signature(s) All current party(ies) signature(s)
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
Name of Entity Name of Entity Name of Entity
___________________________ ___________________________ ___________________________
Signature Signature Signature
___________________________ ___________________________ ___________________________
Title Title Title
Pennsylvania Department of State
Bureau of Corporations and Charitable Organizations
P.O. Box 8722
Harrisburg, PA 17105-8722
(717) 787-1057
Web site:
Instructions for Completion of Form:
A. Typewritten is preferred. If handwritten, the form shall be legible and completed in black or blue-black ink in order
to permit reproduction. The nonrefundable filing fee for this form is $70 made payable to the Department of State.
Checks must contain a commercially pre-printed name and address.
Enter the name and mailing address to which any correspondence regarding this filing should be sent. This field must
be completed for the Bureau to return the filing. If the filing is to be returned by email, an email address must be
provided. An email will be sent to address provided, containing a link and instructions on how a copy of the filed
document or correspondence may be downloaded. Any email or mailing addresses provided on this form will become
part of the filed document and therefore public record.
B. Under 15 Pa.C.S. § 135(c) (relating to addresses) an actual street or rural route box number must be used as an
address, and the Department of State is required to refuse to receive or file any document that sets forth only a post
office box address.
C. The following, in addition to the filing fee, shall accompany this form:
(1) If the amendment effects a change of name, any necessary copies of form DSCB:19-17.2 (Consent to
Appropriation of Name).
(2) Any necessary governmental approvals.
D. For general instructions relating to fictitious name registration see 19 Pa. Code Subch. 17C (relating to Fictitious
names). These instructions relate to such matters as voluntary and mandatory registration, general restrictions on name
availability, use of corporate designators, agent for effecting amendments, etc., execution, official advertising when an
individual is a party to the registration, and effect of registration and non-registration.
E. The name of a commercial registered office provider may not be used in Paragraph 2 or 4B in lieu of an address.
F. An amendment or cancellation shall be signed by all parties to the registration immediately preceding the filing unless
an agent is authorized in the original registration and the agent signs the application. If the amendment adds a new
party, the party added by the amendment must sign the form. In the case of withdrawal, the form need only be signed
by the withdrawing party.
G. If the filing involves a deceased party, the form should be signed by an executor or other fiduciary. It is not
necessary to submit a short certificate showing appointment as fiduciary, etc. See 15 Pa.C.S. § 135(b).
H. There is no requirement that the parties involved in an amended, canceled or withdrawal application advertise their
intention to file or the filing of such application.
I. No certificate will be issued by the Department in response to this filing.
J. This form and all accompanying documents shall be mailed to the address stated above.