Renewal of Fictitious or Assumed Name Certificate : Please fill out the following form. Please print your completed form if you would to have a copy for your records.
The undersigned hereby certify(ies) the following :
1. The undersigned (NAME) is or are conducting a business at (ADDRESS of THE BUSINESS).
2. The most recent prior (Fictitious or Assumed) name certificate was filed with (Name of the office) on (date and year).
3. The true name(s) and residence(s) of each of the undersigned are :
4. This certificate reflects a change in the information set forth in the most recent prior certificate.
This certificate is executed and filed as a renewal certificate pursuant to state law.
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.
Affiant : Known / Unknown :
ID Produced :
Affidavits Forms Index
Renewal of Fictitious or Assumed Name Certificate
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