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Fictitious Business Name Statement
Conditional
Required when doing business under a name different from the owner's
·
Due: 12/10/2024
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Business Identification
Fictitious Business Name (DBA)
Type of entity/business structure
Select Type of entity/business structure
Individual/Sole proprietor
General partnership
Corporation
Limited partnership
Limited liability company
Trust
Unincorporated association
Joint venture
Married couple
State/local registered domestic partners
Limited liability partnership
Church/church-controlled organization
Other nonprofit organization
State of incorporation/organization
Date business started or acquired
Contact Information
Registrant Information
Name
Address
State of Incorporation
Signature
Date