INSTRUCTIONS FOR FICTITIOUS BUSINESS NAME (FBN)
S
TA
TE
M
EN
T AND AFFIDAVIT OF IDENTITY
The form must be legible – no erasures or whiteouts. Strikeovers acceptable if accompanied with initials.
1.
IN PERSON: Registrants will be required to present a completed FBN statement, show a valid government issued identification, and complete an Affidavit of Identity
form.
2.
BY MAIL: Registrant will be required to submit a completed FBN statement, and notarized Affidavit of Identity form. The notarized section can be substituted with
a copy of government issued identification.
3. OTHER: Persons presenting FBN statement on behalf of the registrant must show a valid government issued identification and submit the complete notarized Affidavit
of Identity form. The notarized section can be substituted with a copy of registrant's government issued identification.
Business and Professions Code Section
17913
1. Where (1) appears in the form on the front side:
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.
2. Where (2) appear in the form on the front side:
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 bus
iness in this state, insert the street address, and county of his or her principal place of business outside this
state.
c. Mail Box and Post Office Box Numbers are not acceptable as a business address.
3. Where (3) appear in the form on the front side:
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 registra
nt is a general partnership,
c
o -partnership, joint venture, limited liability partnership, or unincorporated association other
than a partnership, insert the full name and residence address of each general partner. Two or more names
must
be listed as the
registrants.
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 California Secretary of State, and the state of organization.
f. If the registrant is a trust, insert t
he 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 California
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.
4. Where (4) appear in the form on the front side:
a. Indicate which of the terms best describes the nature of the business.
5. Where (5) ap
pear in the form on the front side:
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. If the registrant has not yet commenced to transact business under the Fictitious Business Name or names listed, mark the box “not applicable”.
Business and Professions Code Section 17914
1. The statement shall be signed as follows:
a. If the registrant is an individual, by the individual.
b. If the registr
ants are a married couple, by either party 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
1. 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.
2
. 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
The statement expires upon filing and publication of a statement of Abandonment.
Business and Professions Code Section 17923
The statement does not expire if a withdrawing partner files and publishes a statement of withdrawal and all other facts remain as originally filed.
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).
CC230 (Rev. 07/5/17)
1600 PACIFIC HIGHWAY, SUITE 260, SAN DIEGO, CA 92101
P.O. BOX 121750, SAN DIEGO, CA 92112-1750
(619) 237-0502
Ernest J. Dronenburg,
Jr.
County of San
Diego
Recorder/County
Clerk
www.sdarcc.com
FICTITIOUS BUSINESS NAME STATEMENT
FEE SCHEDULE
FILING: $42.00 (Incl
udes one business name and one business owner on statement)
ADDITIONAL OWNER(S): $5.00 (Fee is exempt to include the name of a spouse when transacting business as a married couple)
ADD BUSINESS NAME(S): $5.00 (Fee applies to additional business names on statement at the same location)
ADDITIONAL COPIES: $2.00 (Additional $1.00 fee for a certification of copy)
All information on this statement is public information and is required to appear in the newspaper pursuant to Business and Professions Code 17913.
(1) FICTITIOUS BUSINESS NAME(S):
a.
Print Fictitious Business Name(s)
b.
Print Fictitious Business Name(s)
(2)
L
OC
ATE
D
AT:
/
/
/ /
Physical Business Address (No P.O. Box or Postal Mailbox Facilities) City State County Zip Code
/
/ /
Mailing Address (If different from above) City State Zip Code
(3) REGISTRANT INFORMATION: (Individual, Corp., LLC, Gen. Partner, etc.)
a.
Print Full Complete Name (e.g. First, Middle, Last or Corp. /LLC)
/
/ /
Residence Address, if Corp. or LLC enter physical address (No P.O. Box or Postal Mailbox Facilities) City State Zip Code
If Corporation or LLC Print State of Incorporation/Organization
b.
Print Full Complete Name (e.g. First, Middle, Last or Corp. /LLC)
/
/ /
Residence Address, if Corp. or LLC enter physical address (No P.O. Box or Postal Mailbox Facilities) City State Zip Code
If Corporation or LLC Print State of Incorporation/Organization
(4) THIS BUSINESS IS CONDUCTED BY: (Please check one)
A. Individual
E. Joint Venture
I. Limited Liability Company
B. Married Couple
F. Corporation
J. Limited Liability Partnership
C. General Partnership
G. Trust
K. Unincorporated Association-Other than a Partnership
D. Limited Partnership
H. Co-Partners
L. State or Local Registered Domestic Partners
(5) REGISTRANT FIRST COMMENCED TO TRANSACT BUSINESS UNDER THE ABOVE NAME(S) AS OF (MM/DD/YYYY): ____/____/____ (Cannot be a future date)
CHECK HERE IF THE REGISTRANT HAS NOT YET BEGUN TO TRANSACT BUSINESS UNDER THE NAME(S) ABOVE
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 Business and Professions 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).)
(6) Print Name of Registrant:
Signature of Registrant:
Print Name of Signor: ______________________________________________ Print Title of Person Signing: ________________________________________
This statement was filed with the San Diego Recorder/County Clerk as indicated by the file stamp above.
NOTICE: IN ACCORDAN
CE WITH SUBDIVISION (a) OF SECTION 17920, A FICTITIOUS NAME STATEMENT GENERALLY EXPIRES AT THE END OF FIVE YEARS (5) 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 PROFESSIONS CODE)
CC230 (Rev. 07/5/17)
(Print name as it appears above on the statement)
(If Corporation or LLC) (If Corporation or LLC)
1600 PACIFIC HIGHW
AY, SUITE 260, SAN DIEGO, CA 92101
P.O. BOX 121750, SAN DIEGO, CA 92112-1750
(619) 237-0502
Ernest J. Dronenbu
rg,
Jr.
County of San
Diego
Recorder/County
Clerk
www.sdarcc.com
AFFIDAVIT OF IDENTITY-FICTITIOUS BUSINESS NAME STATEMENT
In accordance with Section 17913 of the California Business and Professions Code, the following information is required
to file a Fictitious Business Name Statement.
(1) REGISTRANT FILING INFORMATION:
Fictitious Business Name ______________________________________________________________________
Registrant Nam
e __________________________________________________________________________
Print Full Complete Name (e.g. First, Middle, Last or Corp. /LLC) - As it appears in Section 3 of Statement
Registrant Ad
dress _________________________________________________________________________
Residence Address, if Corp. or LLC enter physical address (No P.O. Box or Postal Mailbox Facilities)
__________________________
_______________________________________________
City State Zip Code
I, certify under penalty of perjury under the laws of the State of California
(Print Name of Registrant/Signor on Statement)
that I am the registrant / authorized signer who has signed this Fictitious Business Name Statement and I am authorized to
submit said statement to the County Clerk’s Office for filing. I understand that if I willfully make a false statement on this
affidavit, I may be guilty of a misdemeanor punishable by a fine not to exceed one thousand dollars
($1,000.00).
I declare tha
t all information is this statement is true and correct.
Signed on thi
s ________day of ______________, 20_____, ___________________________________________
(Signature of Registrant/Signor on Statement)
For Office Use ONLY: By Mail
Registrant ID: Driver’s License □ Identification Card □ Passport Other _________________________
CC312 (Rev. 07/5/17) Page 1
(2) BY MAIL/THIRD PARTY
A copy of a valid, government issued identification may be submitted with your Fictitious Business Name Statement in
lieu of completing this section in front of a Notary Public.
TO BE COMPLETED BY
NOTARY PUBLIC
State of California
)
) ss.
County of )
Subscribed and sworn to (or affirmed) before me on this ______ day of _____________, 20___,
by _____________________________________________________, proved to me on the basis of satisfactory evidence
(Name of Person Appearing)
to be the person(s) who appeared before me, ___________________________________.
(Signature of Notary Public)
(Notary Se
al)
(3) THIRD PARTY FILING
I, _____________________________ d
eclare under penalty of perjury under the laws of the State of California that I am
(Print Name of Registrant/Signor on Statement)
the registrant / authorized signer who has signed this Fictitious Business Name Statement and I am authorized to submit said
statement to the County Clerk’s Office for filing.
I am authori
zing _____________________________ as my Authorized Agent to submit this Fictitious Business Name
(Print Name of Authorized Agent)
Statement on my behalf.
I understand that if I willfully make a false statement on this affidavit, I may be guilty of a misdemeanor punishable by a fine
not to exceed one thousand dollars
($1,000.00).
I declare that all information is this statement is true and correct.
Signed on this
________day of ______________, 20_____ _______________________________________________
(Signature of Registrant)
(4) TO BE COMPLETED BY THE AUTHORIZED AGENT
Agent Name ______________________________________________________________________________________
(First Name) (Last Name)
Fictitious Business Name____________________________________________________________________________
I, ___________________________
__, declare under penalty of perjury under the laws of the State of California that I am
the authorized agent filing this Fictitious Business Name on behalf of the registrant.
Signed on this ________day of ______________, 20_____ _______________________________________________
(Signature of Authorized Agent)
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which
this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
For Office Use ONLY:
Agent ID: □ Driver’s License □ Identification Card □ Passport □ Other ______________________
CC312 (Rev. 07/5/17)
Page 2
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome