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FICTITIOUS BUSINESS NAME STATEMENT This space for use of County Clerk
FILE # ___________________________
NEVADA COUNTY CLERK-RECORDER
TYPE OF FILING (Check one) Eric Rood Administrative Center
o Original 950 Maidu Ave. Nevada City, CA 95959
o New Filing (530) 265-1221
(Change(s) in facts from previous filing)
o Refile FILING FEE
$24.00 - One Business Name and one Owner
(No change(s) in facts from previous filing)
$2.00 - For each additional Partner/Owner in
excess of one Partner/Owner
Previous File # ________________
$5.00 - For each additional Business Name
Fill in this form on your screen, then filed on the same statement and doing
print, sign and submit FOUR COPIES business at the same location

The following person (persons) is (are) doing business as:

* ______________________________________________________________________________ Print Fictitious Business Name[s] on the line above.

** ___________________________________________ _________________________________
` Street Address of principal place of business Mailing address if different

___________________________________________ _________________________________
City State ZIP COUNTY City State ZIP

*** REGISTERED OWNERS:

#1: #2:
BEFORE COMPLETING THIS SECTION,
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________________________________________________________________________ ________________________________________________________________________
Full Name Full Name

________________________________________________________________________ ________________________________________________________________________
Residence Address if not incorporated; State of Incorporation if incorporated. Residence Address if not incorporated; State of Incorporation if incorporated.

________________________________________________________________________ ________________________________________________________________________
City and ZIP City and ZIP

#3: #4:
________________________________________________________________________ ________________________________________________________________________
Full Name Full Name

________________________________________________________________________ ________________________________________________________________________
Residence Address if not incorporated; State of Incorporation if incorporated. Residence Address if not incorporated; State of Incorporation if incorporated.

________________________________________________________________________ ________________________________________________________________________
City and ZIP City and ZIP

(If more than 4 Registrants, attach additional sheet showing Owner information.)

**** This business is conducted by:

   o a Limited Liability Company
o a Trust o Copartners
o an Individual o a General Partnership o a Limited Partnership
o an Unincorprated Association other than a Partnership
o Husband and Wife o a Joint Venture
o a Corporation

  o State or Local Registered Domestic Partners o a Limited Liability Partnership

***
The registrant commenced to transact business under the fictitious business name[s] listed above on this date: _______________

**
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.)
SIGNATURE OF REGISTRANT: ______________________________________________
______________________________________________
(Enter name of person signing and, if a Corporate Officer, also state Title.)
THIS STATEMENT WAS FILED WITH THE COUNTY CLERK OF NEVADA COUNTY ON DATE INDICATED ABOVE.

CERTIFICATION
I hereby certify that the foregoing is a full, true and correct copy of the original on file in this office.
Gregory J. Diaz, Clerk-Recorder By: _____________________________________, Deputy
Fill in this form on your screen, then print, sign and submit FOUR COPIES.
FBN statement--Online Revised 1/1/2008