STATEMENT OF ABANDONMENT OF USE OF

FICTITIOUS BUSINESS NAME

MAIL TO: FILING FEES:
Placer County Clerk $30.00 – INCLUDES THE FIRST
2954 Richardson Dr. BUSINESS NAME
Auburn, CA 95603 $5.50 – FOR EACH ADDITIONAL
(530) 886-5610 BUSINESS & OWNER’S NAME
(This statement was filed with the Placer
County Clerk on the filed date stamped above)

This form may only be used to abandon a Placer County Fictitious Business Name
Statement that had been filed within the past five years. To complete this form, enter the
information exactly as it appeared on the original filing that is being abandoned.
B&P Code 17922
1. FICTITIOUS BUSINESS NAME STATEMENT FILE NO.
Original File #

2. Fictitious Business Name(s) being abandoned:

Original Business Name

(If more space is needed - attach an additional sheet showing owner information.)
3. Street address of business:
Original Business Street Address, City, State, Zip

4. Date of filing being abandoned:

5. Full name(s) & complete street address of original registrant(s): (If more space is needed- attach an additional sheet showing owner information.)

I. II.
(*) Full Name-Type/Print (*) Full Name-Type/Print

Street Address Street Address

City, State, Zip City, State, Zip

(*) In the case of an individual, the full name and address of the individual is to be inserted. In the case of a corporation, the name of the
corporation as set forth in its articles of incorporation and the state of incorporation is to be inserted. In the case of a business trust, the full
name and residence address of each of the trustees is to be inserted. (Attach additional sheet, if necessary.)

6 Business was conducted by: (Check one of the following)

( ) an individual ( ) a General Partnership ( ) a Limited Partnership ( ) a Limited Liability Company ( ) a Trust

( ) an Unincorporated Association other than a Partnership ( ) a Corporation ( ) Copartners ( ) Husband and Wife
( ) Joint Venture ( ) State of Local Registered Domestic Partners ( ) a Limited Liability Partnership

“I declare that all information in this statement is true and correct.” (A REGISTRANT WHO DECLARES AS TRUE
INFORMATION WHICH HE/SHE KNOWS TO BE FALSE IS GUILTY OF A CRIME.) Section 17913(c) B&P Code

7. Signed: (Individual, general partner, trustee or officer)

***Original Registrants Signature

***If the person is an individual, the statement shall be signed by the individual; if a partnership or other association of persons, by general
partner; if a trust, by trustee; if a corporation, by an officer. (Section 17914 Business & Professions Code)

READ INSTRUCTIONS FOR COMPLETION OF ABANDONMENT

The Abandonment is to be filed EXACTLY as the Fictitious Business Name Statement was originally filed. (Section 17922 B&P Code)

• The Statement of Abandonment of Use of Fictitious Business Name must be published in a newspaper once a week for four consecutive
weeks (NOTE: FIRST PUBLICATION MUST START WITHIN 30 DAYS FROM COUNTY CLERKS FILE DATE) and an affidavit of publication
filed with the county clerk within 30 days after publication has been accomplished. The statement should be published in a newspaper of
general circulation in the county where the principal place of business was located. The statement should be published in such county in a
newspaper that circulates in the area where the business was conducted.

• Any person who executes, files, or publishes any fictitious business name statement, knowing that such statement is false, (in whole or Rev
part) is
04/07
guilty of a misdemeanor and upon conviction thereof shall be fined not to exceed five hundred dollars ($500). (Section 17930 B&P Code)
THE ABOVE INSTRUCTONS ARE NOT TO BE PUBLISHED. (Section 17924 Business & Professions Code)
Revised 8/21/2008