Fillable Office of the Minnesota Secretary of State (Minnesota Department of Revenue)

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Office of the Minnesota Secretary of State (Minnesota Department of Revenue)

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Office of the Minnesota Secretary of State
Assumed Name | Cancellation of Assumed Name
Minnesota Statutes, Chapter 333
Read the instructions before completing this form.
This is a request to cance
l the Certificate of Assumed Name currently on record with the Office of the
Secretary of State.
1. Assumed Name: (Required)
2. Certificate of Assumed Name File Number:
3.
This Assumed Name was originally filed on:
4. All current nameholders or an authorized agent must sign the cancellation. Attach additional sheet(s) if necessary.
I, the un
dersigned, certify that I am signing this document as the person whose signature is required, or as agent of
the person(s) whose signature would be required who has authorized me to sign this document on his/her behalf, or
in both capacities. I further certify that I have completed all required fields, and that the information in this
document is true and correct and in compliance with the applicable chapter of Minnesota Statutes. I understand that
by signing this document I am subject to the penalties of perjury as set forth in Section 609.48 as if I had signed this
document under oath.
Signature of all Partners or an Authorized Agent
Print Name(s)
Email Address for Officia
l Notices
Enter an email address to which the Secretary of State can forward official notices required by law and other notices:
Check here to have your email address excluded from requests for bulk data, to the extent allowed by Minnesota
law.
List a name and daytime phone number of a person who can be contacted about this form:
Contact Name Phone Number
AssumedNameCancellationRev.7/15/2020
Date
There is no fee for expedited service in-person, online filing or by mail for cancelling an Assumed Name.
Print
Reset
INSTRUCTIONS
File your business document online by visiting our website at www.sos.state.mn.us.
This form is intended merely as a guide for filing and is not intended to cover all situations. Retain the original
signed copy of this document for your records and submit a legible photocopy for filing with the Office of the
Secretary of State.
1. List the business name of file with the Office of the Secretary of State. (Required)
2. List the original Certificate of Assumed Name number.
3. List the date on which the original was filed.
4.
All current nameholders or an Authorized Agent (T
he signing party must indicate on the document that they
are acting as the agent of the person(s) whose signature would be required and that they have been
authorized
to sign on behalf of that p
erson(s).) must sign this cancellation form
.
Email
Address for Official Notices. This email address may be used to send annual renewal reminders and other
important notices that may require action or response. Check the box if you wish to have your email address excluded
from requests for bulk data, to the extent allowed by Minnesota law.
List a name and daytime telephone number of a person who can be contacted about this form.
There is no fee for cancelling an Assumed Name.
Please submit all items together and mail to the address below:
FILE IN-PERSON OR MAIL TO:
Minnesota Secretary of State - Business Services
Retirement Systems of Minnesota Building
60 Empire Drive, Suite 100
St Paul, MN 55103
(Staffed 8 a.m. – 4 p.m., Monday - Friday, excluding holidays)
Phone Lines: (9 a.m. - 4 p.m., M-F) Metro Area 651-296-2803; Greater MN 1-877-551-6767
All of the information on this form is public. Minnesota law requires certain information to be provided for this type
of filing. If that information is not included, your document may be returned unfiled. This document can be made
available in alternative formats, such as large print, Braille or audio tape, by calling (651)296-2803/voice. For a
TTY/TTD (deaf and hard of hearing) communication, contact the Minnesota Relay Service at 1-800-627-3529 and
ask them to place a call to (651)296-2803. The Secretary of State's Office does not discriminate on the basis of race,
creed, color, sex, sexual orientation, national origin, age, marital status, disability, religion, reliance on public
assistance or political opinions or affiliations in employment or the provision of service.
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Office of the Minnesota Secretary of State (Minnesota Department of Revenue)

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Completed 1 April 2021

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