Certificate of Termination of Business Under A Fictitious or Assumed Name : Please fill out the following form. Please print your completed form if you would to have a copy for your records.




The following is hereby certified :


1. Pursuant to state law, a certificate to conduct business under the name (Enter either Fictitious or Assumed) of (Enter the name of business) at (Enter the address of business) was filed in the office of the (Enter the applicable state office) on (date)by (Enter the name of the person who filed certificate) and (Enter the name of the person filing if any).


2. The filing of such certificate is no longer required for the following reason (Enter the reasons).


3. The undersigned constitute majority of the persons named in the original or in the most recent amended certificate as conducting business under the name (Enter either Fictitious or Assumed) of (Enter the name of business) at (Enter the name of business).


Date :


STATE OF :


COUNTY OF :


On _______________________ before me _________________________ personally appeared ___________________________ personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.


WITNESS my hand and official seal.


Signature :


Affiant : Known / Unknown :


ID Produced :


Seal :





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