Kern County Auditor-Controller-County Clerk
1115 Truxtun Avenue, First Floor
Bakersfield, CA 93301 (661) 868-3588
STATEMENT OF ABANDONMENT OF USE OF FICTITIOUS BUSINESS NAME
Instructions: Please type or write legibly, and complete all applicable sections. Incomplete forms will be returned. Submit one
original and two copies. If filing by mail, provide a self-addressed, stamped envelope.
1
Business Name you wish to abandon:
2
Street address of business:
Mailing address: (DO NOT WRITE THE WORD “SAME”)
3
Registrant(s) who wish to abandon the business name: (Use a second form to list more registrants.)
A
Name:
B
Name:
Residence Address (P.O. Box not acceptable):
Residence Address (P.O. Box not acceptable):
City:
State:
Zip:
City:
State:
Zip:
C
Name:
D
Name:
Residence Address (P.O. Box not acceptable):
Residence Address (P.O. Box not acceptable):
City:
State:
Zip:
City:
State:
Zip:
I declare that all information in this Statement is true and correct. (A registrant who declares as true information, which he or she
knows to be false, is guilty of a crime.)
4
Business was conducted by: (Mark one only)
Individual Corporation
General Partnership Trust
Limited Partnership Limited Liability Company
Co-partners Married Couple
Unincorporated Association Joint Venture
Domestic Partners Limited Liability Partnership
5
Signature:
Printed name:
Title:
Daytime telephone number:
6
If filing by mail, please provide mailing address you wish the processed statement to be
returned to:
Address:
C
it
y: State: Zip:
Daytime Contact Phone
Number:
After your statement is processed, it must be published once a week for four successive weeks, (publication to start within 30 days of
the filing date and an affidavit of publication of the statement shall be filed with the County Clerk within 30 days after the completion
of the publication.) B&P 17922(a)
*** DO NOT TYPE OR WRITE BELOW THIS LINE *** COUNTY CLERK USE ONLY ***
Original FBN Statement File Number:
Original FBN Statement Filed on: This statement of Abandonment filed on: (mm/dd/ccyy)
This statement was filed with the County Clerk
of Kern County on the date indicated by the filed
stamp in the upper right corner.
I HEREBY CERTIFY THAT THIS IS A CORRECT COPY OF THE
ORIGINAL STATEMENT ON FILE IN MY OFFICE.
MARY B. BEDARD, C
P
A, Auditor-Controller-County Clerk
By: ( ), Deputy
