Fill and Sign the Business Ownership Certificate Form

Mark the applicable boxes Certificate of Status — $10 Certified Copy — $30NON-REFUNDABLE PROCESSING FEE: $50 1 . ________________________________________________________________________________Fictitious Name to be Registered (see instructions if name includes “Corp” or “Inc”) ____________________________________________________________ ____________________________________________________________ Mailing Address of Business ____________________________________________________________ City Stat e Zip Code 3. Florida County of principal place of business: ______________ ____________________________________________________________ (see instructions if more than one county) FEI Number: ________________________________ A. Owner(s) of Fictitious Name If Individual(s): (Use an attachment if necessary): 1. ______________________________________ 2. ______________________________________ Last First M.I. Last First M.I. ______________________________________ ______________________________________ Address Address ______________________________________ ______________________________________ City State Zip Code City State Zip Code B. Owner(s) of Fictitious Name If other than an individual: (Use attachment if necessary): 1. ______________________________________ 2. ______________________________________ Entity Name Entity Name ______________________________________ ______________________________________ Address Address ______________________________________ ______________________________________ City State Zip Code City State Zip Code Florida Document Number _ ____________ _ Florida Document Number __________ _____ FEI Number: __________________________ FEI Number: __________________________ Applied for Not Applicable Applied for Not Applicable FOR CANCELLATION COMPLETE SECTION 4 ONLY: FOR FICTITIOUS NAME OR OWNERSHIP CHANGE COMPLETE SECTIONS 1 THROUGH 4: I (we) the undersigned, hereby cancel the fictitious name ______________________________ ______________________, which was registered on ________________ and was assigned registration number ______________________ __________________________________________ __________________________________________ Signature of Owner Date Signature of Owner Date APPLICATION FOR REGISTRATION OF FICTITIOUS NAME Note: Acknowledgements / certificates will be sent to the address in Section 1 only. This space for office use only Section 3 Section 1 Section 4 Section 2 CR4E001 (9/1 0) I the undersigned, being an owner in the above fictitious name, certify that the information indicated on this form is true and accurate. In accordance with Section 865.09, F.S., I further certify that the fictitious name to be registered has been advertised at least once in a newspaper as defined in chapter 50, Florida Statutes, in the county where the princi pal place of business is located. I understand that the signature below shall have the same legal effect as if made under oath and I am aware that false information submitted in a document to the Department of State constitutes a third degree felony as provided for in s.817.155, F.S. __________________________________________ __________________________________________ Signature of Owner Date E-mail address: (to be used for future renewal notification) Phone Number:_ Instructions for Completing Application for Registration of Fictitious Name Section 1: Line 1: Enter the name as you wish it to be registered. A fictitious name may not contain the words “Corporation” or “Incorporated,” or the abbreviations “Corp.” or “Inc.,” unless the person or business for which the name is registered is incorporated or has obtained a certificate of authority to transact business in this state pursuant to chapter 607 or chapter 617 Florida Statutes. Corporations are not required to file under their exact corporate name. Line 2: Enter the mailing address of the business. This address does not have to be the principal place of business and can be directed to anyone’s attention. DO NOT USE AN ADDRESS THAT IS NOT YET OCCUPIED. ALL FUTURE MAILINGS AND ANY CERTIFICATION REQUESTED ON THIS REGISTRATION FORM WILL BE SENT TO THE ADDRESS IN SECTION 1. An address may be changed at any future date with no charge by simply writing the Division. Line 3: Enter the name of the county in Florida where the principal place of business of the fictitious name is located. If there is more than one county, list all applicable counties or state “multiple”. Line 4: Enter the Federal Employer Identification (FEI) number if known or if applicable. Please do not enter your social security number. Section 2: Part A: Complete if the owner(s) of the fictitious name are individuals. The individual’s name and address must be provided. Part B: Complete if the owner(s) are not individuals. Examples are a corporation, limited partnership, joint venture, general partnership, trusts, fictitious name, etc. Provide the name of the owner, their address, their document number as registered with the Division of Corporations, and the Federal Em- ployer Identification (FEI) number. An FEI number must be provided or the appropriate box must be checked. Owners listed in Part B must be registered with the Division of Corporations or provide documenta- tion as to why they are not required to register. Examples would be Federally Chartered Corporations, or Legislatively created entities. Additional owners may be listed on an attached page as long as all of the information requested in Part A or Part B is provided. Section 3: Only one signature is required. It is preferred that a daytime phone number be provided in order to contact the applicant if there are any questions about the application. Section 4: TO CANCEL A REGISTRATION ON FILE: Provide fictitious name, date filed, and registration number of the fictitious name to be cancelled. TO CHANGE OWNERSHIP OF A REGISTRATION: Complete section 4 to cancel the original registration. Complete sections 1 through 3 to re-register the fictitious name listing the new owner(s). An owner’s signature is required in both sections 3 and 4. TO CHANGE THE NAME OF A REGISTRATION: Complete section 4 to cancel the original registration. Complete sections 1 through 3 to re-register the new fictitious name. An owner’s signature is required in both sections 3 and 4. An acknowledgement letter will be mailed when the fictitious name registration has been filed. The acknowledgement letter and any certification requested will be mailed to the address provided in Section 1. For Cancellations Only: please provide a mailing address on an attachment, if the address on our records is no longer valid. To request a certificate of status and/or certified copy, please check the appropriate box(es) and include the additional fee(s) ($10 for a certificate of status, $30 for a certified copy). The registration and reregistration will be in effect until December 31 of the fifth year. Send completed application with appropriate fees to: Fictitious Name Registration PO Box 1300 Tallahassee, FL 32302-1300 The fee for registering a fictitious name is $50. Please make a separate check for each filing payable to the Department of State. Application must be typed or printed in ink and legible. Internet Address: http: / / www.sunbiz.org Courier Address Division of Corporations Clifton Building 2661 Executive Center Circle Tallahassee, FL 32301 CR4E001 (11/ 09) Single