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Affidavit Of Identity-Fictitious Business Name Statement ACR 502 - California

Affidavit Of Identity-Fictitious Business Name Statement Form. This is a California form and can be used in Clerk Recorder Assessor County Clerk Recorder Riverside Local County .
 Fillable pdf Last Modified 3/27/2014
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LARRY W. WARD COUNTY OF RIVERSIDE ASSESSOR-COUNTY CLERK-RECORDER Assessor (951) 955-6200 County Clerk-Recorder (951) 486-7000 Mailing Address P.O. Box 751 Riverside, CA 92502-0751 www.riversideacr.com www.riversidetaxinfo.com AFFIDAVIT OF IDENTITY ­ FICTITIOUS BUSINESS NAME STATEMENT In accordance with Section 17913 of the California Business and Professions Code, the following identifying information is required to file a Fictitious Business Name Statement. This certificate must be signed in the presence of a Notary or Deputy County Clerk Registrant Name* Name of Business Registrant Address Street Address _____________________________ Print Full Complete Name (e.g. First, Middle, Last or Corp./LLC/LLP) City State Zip Code I, (Print Name) , certify under penalty of perjury under the laws of the State of California that I am the registrant filing this Fictitious Business Name Statement and am authorized to submit said statement to the County Clerk's Office for filing. I understand that if I willfully make a false statement on this affidavit, I may be guilty of a misdemeanor punishable by a fine not to exceed one thousand dollars ($1,000.00). I declare that all information in this statement is true and correct. Signed on this day of (Day) (Month) , 20___ (Registrant Signature) *If corporation, limited liability company, or limited liability partnership, an original "Certificate of Status" issued by the Secretary of State must be attached. To be completed by Deputy County Clerk Registrant Information: State / ID #_______________________ Exp. Date__________ Deputy Signature________________________ (For Mail Requests Only) STATE OF CALIFORNIA County of ) ) ss ) Subscribed and sworn to (or affirmed) before me on this ______day of ____________, 20___, by _______________________, proved to me on the basis of satisfactory evidence to be the person(s) who appeared before me. _______________________________________ Signature of Notary Public ACR 502 (Rev. 03/2014) Available in Alternate Formats (Notary Seal) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com TO BE COMPLETED BY REGISTRANT The below statement must be signed by the registrant prior to being submitted by the agent. I, (Print Name) , certify under penalty of perjury under the laws of the State of California that I am the registrant filing this Fictitious Business Name Statement and am authorized to submit said statement to the County Clerk's office for filing. I am authorizing the Authorized Agent listed below to submit this Fictitious Business Name Statement on my behalf. I understand that if I willfully make a false statement on this affidavit, I may be guilty of a misdemeanor punishable by a fine not to exceed one thousand dollars ($1,000.00). Signed on this day of (Day) (Month) , 20___ (Registrant Signature) TO BE COMPLETED BY AUTHORIZED AGENT In accordance with Section 17913 of the California Business and Professions Code, the following identifying information is required to file a Fictitious Business Name Statement. This certificate must be signed in the presence of a Deputy County Clerk Agent Name First Name Last Name Fictitious Business Name: I, (Print Name) , declare that I am the authorized agent filing this Fictitious Business Name Statement on behalf of the registrant. Signed on this day of (Day) (Month) , 20___ (Authorized Agent Signature) To be completed by Deputy County Clerk Agent Information: State / ID #_______________________ Exp. Date__________ Deputy Signature________________________ ACR 502 (Rev. 03/2014) Available in Alternate Formats Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com
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