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FBNS.docx Rev. 7/2019 THIS STATEMENT IS A PUBLIC RECORD FILING STAMP ONLY (SEE REVERSE SIDE FOR LEGAL REQUIREMENTS AND INSTRUCTIONS) San Francisco County Clerk 1 Dr. Carlton B. Goodlett Place, Room 168 San Francisco, CA 94102-4678 www.sfgov.org/countyclerk FILING FEE: (See website for methods of payment) $ 55.00 For 1st Business Name and 1st Registrant $ 13.00 For each additional business name or each additional registrant (owner) on SAME statement ITEMS #1 THROUGH #6 MUST BE LEGIBLE AND FULLY COMPLETED; SUBMIT FORM IN DUPLICATE FICTITIOUS BUSINESS NAME STATEMENT 1. Fictitious Business Name(s)/Trade Name (DBA): 2. 4. The business is conducted by: an individual a general partnership a corporation a limited partnership an unincorporated association other than a partnership a trust co-partners a married couple joint venture a limited liability company state or local registered domestic partners a limited liability partnership 5. The registrant commenced to transact business under the fictitious business name or names listed above on : ( enter EXACT date 6. I declare that all information in this statement is true and correct. (A registrant who declares as true any material matter pursuant to Section 17913 of the Business and Professions Code that the registrant knows to be false is guilty of a misdemeanor pun ishable by a fine not to exceed one thousand dollars ($1,000). ) ORIGINAL/WET SIGNATURE REQUIRED. If r egistrant other than Corp. or LLC, sign below Signed Printed Name If registrant is a Corporation or Limited Liability Company, sign below Corporation or LLC Name: Signature Printed Name & Title This statement was filed with the San Francisco County Clerk on date indicated by the file stamp above. NOTICE IN ACCORDANCE WITH SUBDIVISION (a) OF SECTION 17920, A FICTITIOUS NAME STATEMENT GENERALLY EXPIRES AT THE END OF FIVE YEARS FROM THE DATE ON WHICH IT WAS FILED IN THE OFFICE OF THE COUNTY CLERK, EXCEPT, AS PROVIDED IN SUBDIVISION (b) OF SECTION 17920, WHERE IT EXPIRES 40 DAYS AFTER ANY CHANGE IN THE FACTS SET FORTH IN THE STATEMENT PURSUANT TO SECTION 17913 OTHER THAN A CHANGE IN THE RESIDENCE ADDRESS O F A REGISTERED OWNER. A NEW FICTITIOUS BUSINESS NAME STATEMENT MUST BE FILED BEFORE THE EXPIRATION. THE FILING OF THIS STATEMENT DOES NOT OF ITSELF AUTHORIZE THE USE IN THIS STATE OF A FICTITIOUS BUSIN ESS NAME IN VIOLATION OF THE RIGHTS OF ANOTHER UNDER F EDERAL, STATE, OR COMMON LAW (SEE SECTION 14411 ET SEQ., BUSINESS AND PROFESSIONS CODE). CERTIFICATION I hereby certify that the foregoing is a correct copy of the original on file with the San Francisco County Clerk. By , Deputy County Clerk 3. Full name of registrant /owner #1 (If Corporation or Limited Liability Company , also indicate State of incorporation or organization , e.g. (CA ), (DE), etc ) Residence Address (P.O. Box NOT allowed) City, State and Zip Code Full name of registrant /owner #2 (If Corporation or Limited Liability Company , also indicate State of incorporation or organization , e.g. (CA ), (DE), etc ) Residence Address (P.O. Box NOT allowed) City, State and Zip Code Full name of registrant /owner #3 (If Corporation or Limited Liability Company , also indicate State of incorporation or organization , e.g. (CA ), (DE), etc ) Residence Address (P.O. Box NOT allowed) City, State and Zip Code Full name of registrant /owner #4 (If Corporation or Limited Liability Company , also indicate State of incorporation or organization , e.g. (CA ), (DE), etc ) Residence Address (P.O. Box NOT allowed) City, State and Zip Code Street Address, City, State and Zip code of Principal Place of Business (P.O. Box NOT allowed) MUST ENTER COUNTY OF FBN ADDRESS: Any alterations, deletions, or other format to this two - page form will not be accepted for filing by the Office of the SF County Clerk. TTX Cert#: Current: ID MAIL ABOVE FOR OFFICE USE ONLY American LegalNet, Inc. www.FormsWorkFlow.com FBNS.docx Rev. 7/2019 NOTICE TO REGISTRANT PURSUANT TO CA BUSINESS & PROFESSIONS CODE 17900 et seq. & SF BUS. & TAX REG. Article 12 1. Search our index (available at our office or online at www.sfgov.org/countyclerk ) for the fictitious business name(s) (FBN) you plan to file. It is your Other http://www.ss.ca.gov/business/corp/corporate.htm , the U.S. Patents and Trademark Office at http://www.uspto.gov/ or the S.F. Public Main Library. 2. You must register your business with the S.F. Tax Collector located at City Hall, Room 140, (415) 554-4400, www.sfgov.org/tax prior to submitting FBN statement. 3. If filing in person, person must present valid legal photo identification (CA B&P Code Sec. 17916, eff. 01/01/2014) or mail completed FBN statement along with the filing fee (stated at top of form), proof of registration with the S.F. Tax Collector and include a self-addressed stamped envelope. New accounts require receipt issued by the S.F. Tax Collector. Accounts not showing current status . *The fictitious business name statement shall be filed with the county clerk of the county in which the registrant has his or her principal place of business in this state or, if the registrant has no place of business in this state, with the Clerk of Sacramento County. Nothing in this chapter shall preclude a person from filing a fictitious business name statement in a county other than that where the principal place of business is located, as long as the requirements of this subdivision are also met. (B&P Code Sec. 17915)* FIRST FILING: Your fictitious business name statement must be published in a newspaper within 30 days after the statement has been filed with the County Clerk. The statement must be published once a week for four consecutive weeks and an original affidavit proof of publication must be filed with the County Clerk within 30 days after publication has been completed. The statement should be published in a newspaper of general circulation in the county where the principal place of business is located. (B&P Code Sec. 17917) REFILING/RENEWAL: If any change has occurred in the facts in your original statement or your last statement has expired for more than 40 days, your new statement is deemed to be a first filing; therefore, it must be published as required above. If no changes have occurred and your last statement has not lapsed for more than 40 days, publication is not required. This determination is entirely the responsibility of the registrant and should be made at the time of refiling to preclude needless expense. Any person who executes 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 ($1,000.00) (B&P Code Sec. 17930) INSTRUCTIONS FOR COMPLETION OF STATEMENT - Please type or print 1. Insert the fictitious business name or names. Only those businesses operating at the same address may be listed on one statement. (If more than one name, write a small #1, #2, or #3 to the left of each name to ensure all names are indexed properly). 2. If the registrant has a place of business in this state, insert the street address, and county of his or her principal place of business in this state. If the registrant has no place of business in this state, insert the street address, and county of his or her principal place of business outside this state (P.O. Box not acceptable). 3. Registrant Information: If the registrant is an individual, insert full name of registrant and residential address (P.O. Box not acceptable). If the registrant is a general partnership, co-partnership, joint venture, limited partnership, limited liability partnership, or unincorporated association other than a partnership, insert the full name and residential address of each general partner (P.O. Box not acceptable). If the registrant is a trust, insert full name and residential address of each trustee (P.O. Box not acceptable). 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 California Secretary of State and the state of organization (P.O. Box n