Statement of Fictitious or DBA Name

The following persons [list names, partnership, or corporation]
is/are conducting business as [set forth fictitious name] at
[address including street, city, county, and state]. The
complete names and addresses of the individuals or of each
general partner or name of corporation are as follows:

The business is conducted as [individual, general partnership,
limited partnership, unincorporated association, corporation, or
business trust].

Dated:


______________________________
Signature

Statement filed with the County Clerk of [County],
State of [State] on [month][day], [year].