FICTITIOUS OR ASSUMED NAME CERTIFICATE

BY A CORPORATION
CERTIFICATE
The following is hereby certified:
1. Business is, or will be, transacted at:
, under the name of
, a corporation incorporated under the laws of (state), and
authorized to transact business in the State of , with its main office located at:
2. The nature of the business is:
3. The corporation is the sole owner of the business and no other corporation or entity is
interested in the conduct of said business.
This certificate is executed and filed pursuant to:
Date: ___________________________________
STATE OF
}
COUNTY OF
On before me, , personally appeared
, personally known to me (or
proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are
subscribed to the within instrument and acknowledged to me that he/she/they executed the same
in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument
the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
WITNESS my hand and official seal.
Signature___________________________
Affiant _____Known _____Unknown
ID Produced________________________
(Seal)
*NOTE: If you live in New York State, call the New York State Department of Corporation for the
official form.
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