Fill and Sign the Assumed Name PDF Form

Certificate of Assumed Name Pursuant to General Business Law §130 NYS Department of State Division of Corporations, State Records and Uniform Commercial Code One Commerce Plasma, 99 Washington Ave. Albany, NY 12231-0001 www.dos.ny.gov 1. REAL NAME OF ENTITY:       1a. FICTITIOUS NAME, IF ANY, OF FOREIGN ENTITY ( Not Assumed Name):       2. FORMED OR AUTHORIZED UNDER THE FOLLOWING NEW YORK LAW (Check one): Business Corporation Law Limited Liability Company Law Religious Corporations Law Education Law Not-for-Profit Corporation Law Revised Limited Partnership Act Other (specify law):       3. ASSUMED NAME:       4. PRINCIPAL PLACE OF BUSINESS IN NEW YORK STATE (MUST INCLUDE NUMBER AND STREET). IF NONE, CHECK THIS BOX AND PROVIDE OUT-OF- STATE ADDRESS:             5. COUNTY(IES) IN WHICH ENTITY DOES INTENDS TO DO BUSINESS: ALL COUNTIES (Or Check The Applicable County(Ies) Below) Albany Cattaraugus Chenango Delaware Franklin Hamilton Lewis Montgomery Allegany Cayuga Clinton Dutchess Fulton Herkimer Livingston Nassau Bronx Chautauqua Columbia Erie Greene Jefferson Madison New York Broome Chemung Cortland Essex Genesee Kings Monroe Niagara Oneida Orleans Queens St. Lawrence Schuyler Steuben Warren Wyoming Onondaga Oswego Rensselaer Saratoga Seneca Suffolk Washington Yates Ontario Otsego Richmond Schenectady Tompkins Sullivan Wayne Orange Putnam Rockland Schoharie Ulster Tioga Westchester 6. ADDRESS OF EACH LOCATION, INCLUDING NUMBER AND STREET, IF ANY, OF EACH PLACE WHERE THE ENTITY CARRIES ON, CONDUCTS OR TRANSACTS BUSINESS IN NEW YORK STATE. Use page 2 if needed. The address(es) must be a number and street, city state and zip code. The address(es) reflected in paragraph 6 must be within the county(ies) indicated in paragraph 5. If none, check the box: No New York State Business Location                                     Name of Signer:       Signature: Capacity of signer (Check one): Officer of the Corporation General Partner of the Limited Partnership Member of the Limited Liability Company Manager of the Limited Liability Company Authorized Person FILER: Name:       Mailing Address:       City, State and Zip Code:       NOTE: This form was prepared by the New Your State Department of State. You are not required to use this form. All documents should be prepared under the guidance of an attorney. The certificate must be submitted with a $25 fee. For corporations, the Department of State also collects the following, additional, county clerk fees for each county in which a corporation does or intends to do business as indicated in paragraph 5: $100 for each county within New York City (Bronx, Kings, New York, Queens and Richmond) and $25 for each county outside New York City. All checks over $500 must be certified. Page 2 (If needed) DOS-1338-f-l (Rev . 10/13) Page 1 of 2 6. ADDRESS OF EACH LOCATION, INCLUDING NUMBER AND STREET, IF ANY, OF EACH PLACE WHERE THE ENTITY CARRIES ON OR CONDUCTS OR TRANSACTS BUSINESS IN NEW YORK STATE: (CONTINUED)                                                             (For Office Use only) DOS-1338-f-l (Rev . 10/13) Page 2 of 2