Fill and Sign the E Tides Pennsylvania Business Tax System Form

Filing Fee for an Assumed Name $125.00 _____________________ Deputy Secretary of State A True Copy When Attested By Signature _____________________ Deputy Secretary of State Filing Fee for a Fictitious Name $40.00 BUSINESS CORPORATION STATE OF MAINE STATEMENT OF INTENTION TO DO BUSINESS UNDER AN ASSUMED OR FICTITIOUS NAME ______________________________________ (Real Name of Corporation) Pursuant to 13-C MRSA §404 , the undersigned corporation executes and delivers the following Statement of Intention to do Business Under an Assumed or Fictitious Name: FIRST: ("X" one box only.) assumed name ( 13-C MRSA §404.1 ) fictitious name ( 13-C MRSA §404.2 ) The corporation intends to transact business under the assumed or fictitious name of ______________________________________________________________________________________________. Please note: A fictitious name is a name adopted by a foreign corporation authorized to transact business in this State because its real name is unavailable pursuant to 13-C MRSA §401 . Complete the following if applicable: SECOND: If the assumed name is to be used at fewer than all of the cor poration's places of business in this State, the location(s) where it will be used is (are): _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ THIRD: (Foreign Corporation Only) Jurisdiction of incorporation _____________________________________________________ and the date on which the corporation was authorized to transact business in Maine _____________________________________________. FORM NO. MBCA-5 (1 of 2) DATED _________________________ *By __________________________________________________ (signature of any duly authorized person) _________________________________________________ (type or print name and capacity) *This document MUST be signed by any duly authorized officer OR the clerk. ( 13-C MRSA §121.5 ) Please remit your payment made payable to the Maine Secretary of State. SUBMIT COMPLETED FORMS TO: CORPORATE EXAMINING SECTION, SECRETARY OF STATE, 101 STATE HOUSE STATION, AUGUSTA, ME 04333-0101 FORM NO. MBCA-5 (2 of 2) Rev. 8/1/2004 TEL. (207) 624-7752