Fillable MARY B. BEDARD, CPA Kern County Auditor-Controller-County Clerk (Kern County Clerk)

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MARY B. BEDARD, CPA Kern County Auditor-Controller-County Clerk (Kern County Clerk)

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MARY B. BEDARD, CPA
Kern County Auditor-Controller-County Clerk
1115 Truxtun Avenue, Bakersfield, CA 93301
(661) 868-3588
1. Filing fee - $35 for one DBA & one Owner
2. $6 for each additional DBA & Owner
3. Complete all Items 1-6
4. You MUST provide self address stamped
envelope if submitting by mail
FICTITIOUS BUSINESS NAME STATEMENT
1
Fictitious Business Name (Doing Business As) (If listing more than three DBAs, attach addendum sheet as needed.)
DBA #1:
DBA #2:
DBA #3:
2
Street address of principal place of business:
Mailing address of business ( Do not enter “SAME”):
City:
Zip:
County:
City:
State:
Zip:
3
Registrants: (If listing more than three registrants, attach addendum sheet as needed.)
A
Full name of individual, partner, or name of Corporation or LLC:
State of
Incorporation or
Organization:
Residence Street address City State Zip
B
Full name of individual, partner, or name of Corporation or LLC:
State of
Incorporation or
Organization:
Residence Street address City State Zip
C
Full name of individual, partner, or name of Corporation or LLC:
State of
Incorporation or
Organization:
Residence Street address City State Zip
4
(CHECK ONE ONLY) The business is conducted by:
Individual Unincorporated Association Married Couple
General Partnership Corporation Joint Venture
Limited Partnership Trust Domestic Partners
Co-Partners Limited Liability Company Limited Liability Partnership
5
Insert the date the business commenced. (mm/dd/ccyy) If business has not started, enter “N/A”.
NOTICE: IN ACCORDANCE WITH SUBDIVISION (A) OF SECTION 17920, A FICTITIOUS 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 PROFESSIONS CODE.)
6
BY SIGNING BELOW, I DECLARE THAT ALL INFORMATION IN THIS STATEMENT IS TRUE AND CORRECT. A registrant who declares
as true any material matter pursuant to this sections that he or she knows to be false is guilty of a misdemeanor (B&P Code 17913).
I am also aware that all information on this statement becomes public record upon filing pursuant to the California Public Records
Act (Government Code Section 6250-6277).
____________________________________________ _________________________________________________
Signature Printed Name
____________________________________________ _________________________________________________
If Corporation or LLC, print title of person signing Phone # Check box to block # from public
------------------------------------DO NOT TYPE OR WRITE BELOW THIS LINE - COUNTY CLERK USE ONLY-------------------------------
Date Statement Filed:
/ /
Date Statement Expires:
/ /
MARY B. BEDARD, CPA, Auditor-Controller-County Clerk
By: /
*** PUBLICATION NOTICE ***
Initial/Renewal with changes – Must be published once a week for four successive weeks (publication to start within 30 days of
the file date) and an affidavit of publication must be filed with the County Clerk within 30 days after publication has been completed.
Renewal – Publication is not required, pursuant to Business and Professions Code Section 17917(c)
*** BANK CERTIFICATION ***
I hereby certify that the foregoing is a correct copy of the original filed in my office on ______/______/______.
MARY B. BEDARD, Auditor-Controller-County Clerk , By: , Deputy Clerk.
County Clerk Copy
Bank Copy
Newspaper Copy
Registrant Copy
DBA #1:
AFFIDAVIT OF IDENTITY – FICTITIOUS BUSINESS NAME STATEMENT
In accordance with Section 17913 of the CA Business and Professions Code, the following identifying information is required to
file a Fictitious Business Name Statement.
This certificate must be signed in the presence of a Notary Public (mail/drop-off) OR Deputy County Clerk (in person).
Registrant Name __ ______________
First Name Last Name
Name of Business ______________
Registrant Address _____________
Street Address
____________
City State Zip Code
I, _____________________ _, declare under penalty of perjury under the laws of the State of California,
that I am the registrant and intend to file this Fictitious Business Name. I understand that if I willfully make a false statement on
this affidavit, I may be punished by a fine not to exceed one thousand dollars ($1,000).
Signed on this day of ________ 20 __.
(Day) (Month)
(Signature)
If filing as a corporation, limited liability company, or limited liability partnership, an original “Certificate of Status” issued by the
Secretary of State must be attached.
FOR OFFICE USE ONLY: ***TO BE COMPLETED BY DEPUTY COUNTY CLERK FOR IN-PERSON FILINGS ONLY***
ID #:_____________________________ Exp Date: ________________ Deputy Signature: _____________________
CERTIFICATE OF ACKNOWLEDGEMENT
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 Mail or Third Party Requests Only***
STATE OF CALIFORNIA )
) ss
County of )
On , before me __ personally appeared
(Insert name and title of officer here)
____________________________________________, who proved to me on the basis of satisfactory evidence, to be the
person whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her
authorized capacity, and that by his/her signature on the instrument the person, or the entity upon behalf of which the person
acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true.
WITNESS my hand and official seal.
(NOTARY SEAL)
___________________________________
NOTARY SIGNATURE
KERN COUNTY
AUDITOR-CONTROLLER-COUNTY CLERK
MARY B. BEDARD, CPA
KERN COUNTY
AUDITOR-CONTROLLER-COUNTY CLERK
MARY B. BEDARD, CPA
AFFIDAVIT OF IDENTITY – AUTHORIZED AGENT FORM
TO BE COMPLETED BY AUTHORIZED AGENT
In accordance with Section 17913 of the CA Business and Professions Code, the following identifying information is required to
file a Fictitious Business Name Statement.
This certificate must be signed in the presence of a Notary Public (mail/drop-off) OR Deputy County Clerk (n person).
Agent Name __________________________________ ____________________________________________
(First Name) (Last Name)
Fictitious Business Name: ________________________________________________________________________
I, _________________________________, declare that I am the authorized agent filing this Fictitious Business Name on
(Print Name)
On behalf of the registrant.
Signed on this day of ________ 20 __.
(Day) (Month)
(Authorized Agent Signature)
FOR OFFICE USE ONLY: ***TO BE COMPLETED BY DEPUTY COUNTY CLERK FOR IN-PERSON FILINGS ONLY***
ID #:_____________________________ Exp Date: ________________ Deputy Signature: _____________________
CERTIFICATE OF ACKNOWLEDGEMENT
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 Mail-Ins Only***
STATE OF CALIFORNIA )
) ss
County of )
On , before me __ personally appeared
(Insert name and title of officer here)
____________________________________________, who proved to me on the basis of satisfactory evidence, to be the
person whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her
authorized capacity, and that by his/her signature on the instrument the person, or the entity upon behalf of which the person
acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true.
WITNESS my hand and official seal.
(NOTARY SEAL)
___________________________________
NOTARY SIGNATURE
KERN COUNTY
AUDITOR-CONTROLLER-COUNTY CLERK
MARY B. BEDARD, CPA
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MARY B. BEDARD, CPA Kern County Auditor-Controller-County Clerk (Kern County Clerk)

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Completed 3 April 2021

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