______________________________________________________________________________________________________________
Prepared By: (Name, Address, City, State, Zip, Phone #)
______________________________________________________________________________________________________________
Return Document To: (Name & Complete Address if different from Preparer Info)
Trade Name
Verified statements of person or co-partnership conducting a business under a trade name or assumed name. (Chapter 547, Code of Iowa) STATE OF
IOWA, POLK COUNTY,
Names of Person(s) Owning or Having Interest in the Business:
_____________________________________________________________________________________IA____________________
Name Address City Zip
_____________________________________________________________________________________IA____________________
Name Address City Zip
_____________________________________________________________________________________IA____________________
Name Address City Zip
*CHECK ONE BOX PER FORM*
I (we) in compliance with the provisions of Chapter 547, Code of Iowa, hereby establish or amend Trade Name as follows:
Establish Trade Name ____________________________________________________________________________________________________
Name of Business
____________________________________________________________________________________________________________________________
Complete Business Address (Required)
Dissolve Trade Name ____________________________________________________________________________________________________
Original Book _______________________ Page _________________
Add/Withdrawal name(s) of Partner(s) _______________________________________________________________________________________
Name of Business_______________________________________________ Original Book _______________________ Page _________________
Change of Address _______________________________________________________________________________________________________
Business / Home (Circle One) Complete Address
Name of Business_______________________________________________ Original Book _______________________ Page _________________
And that there is no one except those mentioned in the foregoing list who owns or has any interest in the above named business. I (we) further certify that a
corrected statement will be filed in the future each time there may be any change in ownership, as provided by Section 547.2, Code of Iowa.
_____________________________________X _________________________________
Date Signed: ________________
Printed Name Signature
_____________________________________X _________________________________
Date Signed: ________________
Printed Name Signature
_____________________________________X _________________________________
Date Signed: ________________
Printed Name Signature
Subscribed in my presence and sworn to before me by the said _________________________________________________________
this ______ day of ____________________ ____________.
X __________________________________________ Notary Public in and for ________________ COUNTY, _________________.
