CERTIFICATE OF ASSUMED BUSINESS NAME

For persons (sole proprietorships, associations, or general partnerships) engaged in business

under a name other than their own (DBA)

STATE OF __________________, COUNTY OF________________________

NAME OF BUSINESS:_____________________________________________

NATURE OF BUSINESS:___________________________________________

ADDRESS OF BUSINESS:__________________________________________

PRINT NAMES AND RESIDENCES OF MEMBERS OF BUSINESS:

________________________AT______________________________________

________________________AT______________________________________

________________________AT______________________________________

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SECTION TO BE COMPLETED BY/IN PRESENCE OF A NOTARY

I hereby certify that I have personal knowledge of the facts stated above and that each of them is
to be true.

_______________________ ________________________ _____________________

Member’s Signature Printed Name Capacity of Signer

Subscribed and sworn to before me, this _____ day of ___________, 20___.

_______________________ ________________________ _____________________

Signature of Notary Printed Name County of Residence

Expiration date: ____________________

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I affirm, under penalties for perjury, that I have taken reasonable care to redact each Social Security number in this document
unless required by law.

_____________________________________

Prepared By: ____________________________________

 PROOF

Executed and Delivered in my presence:

___________________________________ (witness signature)

____________________________________(witness print)

State of ___________________)
) ss:
County of _________________)

Before me a Notary Public in and for said County and State, personally appeared

______________________________(witness print name), being known to me to be the person

whose name is subscribed as a witness to the foregoing instrument, who, being duly sworn by
me, deposes and says that the foregoing instrument was executed and delivered by

__________________________(grantor/signer name) in the above-named subscribing witness’s

presence , and that the above-named subscribing witness is not a party to the transaction
described in the foregoing instrument at will not receive any interest in or proceeds from the
property that is the subject of the transaction.

Witness my hand and Notarial Seal this ____________ day of ____________________, 2020.

_____________________________ (notary signature)

______________________________(notary printed name)

Commission Number: ________________

County of Residence: ________________

SEAL
Commission Expire: _________________