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Fictitious Business Name Statement ACR 500 - California
| Fictitious Business Name Statement Form. This is a California form and can be used in Clerk Recorder Assessor County Clerk Recorder Riverside Local County . |
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LARRY W. WARD COUNTY OF RIVERSIDE ASSESSOR-COUNTY CLERK-RECORDER P.O. Box 751, Riverside, CA 92502-0751 -- (951) 486-7000 82-675 Hwy. 111, Rm. 113, Indio, CA 92201 -- (760) 863-8732 OFFICE OF THE COUNTY CLERK FICTITIOUS BUSINESS NAME STATEMENT SEE REVERSE SIDE FOR FEES AND INSTRUCTIONS CLERK'S USE ONLY - USE BLACK INK ONLY MUST BE TYPED OR PRINTED INITIAL CROSS OUTS NO WHITE OUT ALLOWED COUNTY CLERK'S FILING STAMP $____________ Fee # _________________________ Receipt Comments: ___________________________________________________ THE FOLLOWING PERSON(S) IS (ARE) DOING BUSINESS AS: 1a. Fictitious Business Name (If more than one business name at same address - Attach Supplemental Sheet) ___________________________________________________________________________________________________________________________________________________________ 1b. List COMPLETE Physical Business Address (No P.O. Boxes or Postal Facilities) Mailing Address (If different than business address optional) 1c. Name of County (where business is located) ___________________________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________ 2a. Registrant Information (Individual, Corp., LLC, Gen. Partner, etc.) ___________________________________________________________________________ 2b. Registrant Information (Individual, Corp., LLC, Gen. Partner, etc.) ___________________________________________________________________________ If individual-spell out first, middle and last names (use dash if no middle name) ___________________________________________________________________________ If individual-spell out first, middle and last names (use dash if no middle name) ___________________________________________________________________________ Residence Address (if Corp. or LLC enter the physical address of the Corp./LCC) __________________________________________________________________________ Residence Address (if Corp. or LLC enter the physical address of the Corp./LCC) __________________________________________________________________________ City State Zip City State Zip ___________________________________________________________________________ ___________________________________________________________________________ List State of Corp./LLC. Must be registered in California 2a. Registrant Information (Individual, Corp., LLC, Gen. Partner, etc.) 2c. Registrant Information (Individual, Corp., LLC, Gen. Partner, etc.) ___________________________________________________________________________ ___________________________________________________________________________ If individual-spell out first, middle and last names (use dash if no middle name) List State of Corp./LLC. Must be registered in California 2d. Registrant Information (Individual, Corp., LLC, Gen. Partner, etc.) ___________________________________________________________________________ If individual-spell out first, middle and last names (use dash if no middle name) If individual-spell out first, middle and last names (use dash if no middle name) ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Residence Address (if Corp. or LLC enter the physical address of the Corp./LCC) __________________________________________________________________________ __________________________________________________________________________ City State Zip Residence Address (if Corp. or LLC enter the physical address of the Corp./LCC) Residence Address (if Corp. or LLC enter the physical address of the Corp./LCC) __________________________________________________________________________ City State Zip ___________________________________________________________________________ ___________________________________________________________________________ City State Zip ___________________________________________________________________________ List State of Corp./LLC. Must be registered in California List State of Corp./LLC. Must be registered in California List State of Corp./LLC. Must be registered in California 3. This business is conducted by: (If More Than four Registrants - Attach Additional Sheet Showing Owner Information) Individual Married Couple Trust Corporation General Partnership A Limited Partnership Co-partners Joint Venture Limited Liability Company Limited Liability Partnership An Unincorporated Association - other than a partnership State or Local Registered Domestic Partnership 4. Registrant has not yet begun to transact business under the fictitious name(s) listed above. Registrant commenced to transact business under the fictitious business name(s) listed above on ____________________________________ I declare that all the information in this statement is true and correct. (A registrant who declares as true, information which he __________________________________________________ or she knows to be false is guilty of a crime.) 5. Signature(s) ______________________________________________________________________________________________________ (Only one is required) Typed or Printed Name(s) ___________________________________________________________________________________________ If Limited Liability Company/Corporation, Title __________________________________________ NOTICE IN ACCORDANCE WITH SUBDIVISION (a) OF SECTION 17920, A FICTITIOUS BUSINESS 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 PRO VIDED IN SUBDIVISION (b) OF SECTION 17920, WHERE IT EXPIRES 40 DAYS AFTER ANY CHANGE IN THE FACTS SET FORTH IN THIS STATEMENT PURSUANT TO SECTION 17913 OTHER THAN A CHANGE IN THE RESIDENCE ADDRESS OF 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 BUSINESS NAME IN VIOLATION OF THE RIGHTS OF ANOTHER FEDERAL, STATE OR COMMON LAW (SEE SECTION 14411 ET SEQ., BUSINESS AND PROFESSIONAL CODE). ACR 500 (Rev. 12/2012) Available in Alternate Formats QC'D BY: ______________________ THIS STATEMENT WAS FILED WITH THE COUNTY CLERK OF R
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