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OFFICE OF THE CLERK This space reserved for County Clerk STATEMENT OF ABANDONMENT OF USE OF FICTITIOUS BUSINESS NAME - FILING FEE FILE NO: The person(s) listed below have abandoned the use of the following fictitious business name(s): Name of Business(es) Street Address, City, State, Zip Code and County The fictitious business name was filed in COUNTY on File Number Insert date filed REGISTERED OWNER(S): 1. 2. Full Name Full Name Residence Address Residence Address City State Zip City State Zip If Corporation or LLC – Print State of Incorporation/Organization If Corporation or LLC – Print State of Incorporation/Organization 3. 4. Full Name Full Name Residence Address Residence Address City State Zip City State Zip If Corporation or LLC – Print State of Incorporation/Organization If Corporation or LLC – Print State of Incorporation/Organization Business was conducted by: (Check one of the following) ( ) an Individual ( ) a General Partnership ( ) a Limited Partnership ( ) a Limited Liability Company ( ) an Unincorporated Association other than a Partnership ( ) a Corporation ( ) a Trust ( ) Copartners ( ) Husband and Wife ( ) Joint Venture ( ) State or Local Registered Domestic Partners ( ) a Limited Liability Partnership 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 Print name of person signing. If corporation, also print corporate title of officer. If LLC, also print title of officer or manager. This statement was filed with the County Clerk of County on the date indicated by the filed stamp in the upper right corner. I HEREBY CERTIFY THAT THIS COPY IS A CORRECT COPY OF THE ORIGINAL STATEMENT ON FILE IN MY OFFICE. COUNTY CLERK Deputy Rev. 01/01/08 ---PAGE BREAK--- THE INSTRUCTIONS BELOW ARE NOT TO BE PUBLISHED (Sec. 17924 B&P) INSTRUCTIONS FOR COMPLETION OF STATEMENT Section 17922 Business & Professions Code Upon ceasing to transact business in this state under a fictitious business name that was filed in the previous five years, a person who has filed a fictitious business name statement shall file a statement of abandonment of use of fictitious business name. The statement shall be executed in the same manner as a fictitious business name statement and shall be filed with the county clerk of the county in which the person has filed his or her fictitious business name statement. The statement shall be published in the same manner as a fictitious business name statement and an affidavit showing its publication shall be filed with the county clerk after the completion of publication. The statement shall include: The name being abandoned and the street address of the principal place of business The date on which the fictitious business name statement relating to the fictitious business name being abandoned was filed, the file number, and the county where filed. If the registrant is an individual, insert his or her full name and residence address If the registrants are husband and wife, insert the full name and residence address of both the husband and the wife If the registrant is a general partnership, limited partnership, copartners, a limited liability partnership, a joint venture, or an unincorporated association other than a partnership, insert the full name and residence address of each general partner 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 CA Secretary of State, and the state of incorporation. If the registrant is a trust, insert the full name and residence address of each trustee 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 CA Secretary of State, and the state of organization If the registrants are state or local registered domestic partners, insert the full name and residence address of each domestic partner The statement shall be signed as follows: If the registrant is an individual, by the individual If the registrants are husband and wife, by the husband or wife 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 If the registrant is a limited liability company, by a manager or officer If the registrant is a trust, by a trustee If the registrant is a corporation, by an officer If the registrant is a state or local registered domestic partnership, by one of the domestic partners The Statement of Abandonment of fictitious business name must be published in a newspaper once a week for four successive weeks and an affidavit of publication filed with the county clerk within 30 days after publication has been accomplished. The statement should be published in a newspaper of general circulation in the county where the principal place of business is located. The statement should be published in such county in a newspaper that circulates in the area where the business is conducted (Business & Professions Code 17917)." 17924 "Any person who executes, file, or publishes any fictitious business name statement, knowing that such statement is false, in whole or in part, is guilty of a misdemeanor and upon conviction thereof shall be fined not to exceed one thousand dollars ($1,000) (Business & Professions Code 17930)." (Statement of Abandonment)