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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, DALLAS COUNTY, Names of Person(s) Owning of 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, _ .