Free CR4E003 new - Florida

FILE TO RENEW NOW: FICTITIOUS NAME WILL EXPIRE ON 12/31/09
FLORIDA DEPARTMENT OF STATE DIVISION OF CORPORATIONS

SECRETARY OF STATE

APPLICATION FOR RENEWAL OF FICTITIOUS NAME REGISTRATION #
1. Name and Mailing Address

t
If above mailing address is incorrect in any way, line through incorrect information and enter correction in Block 2.

CHECK HERE IF MAKING CHANGES

CR4E003 (5/09) 3. County of Principal Place of Business 4. Date Registered

2. Mailing Address change if applicable:

Suite, Apt. #, etc. 5. Certificate of Status Desired City State Zip Code

t $10 Additional Fee Required

AN OWNER THAT IS A CORPORATION, LIMITED PARTNERSHIP OR OTHER BUSINESS ENTITY MUST BE REGISTERED AND ACTIVE WITH THIS OFFICE.
6. CURRENT OWNER (S)
DOCUMENT # FEI # NAME STREET ADDRESS CITY - ST- ZIP DOCUMENT # FEI # NAME STREET ADDRESS CITY - ST- ZIP DOCUMENT # FEI # NAME STREET ADDRESS CITY - ST- ZIP DOCUMENT # FEI # NAME STREET ADDRESS CITY - ST- ZIP

7. ADDITIONS / CHANGES TO OWNERS

t DELETE

DOCUMENT # FEI # NAME STREET ADDRESS CITY - ST- ZIP

t Change

t Addition

t DELETE

DOCUMENT # FEI # NAME STREET ADDRESS CITY - ST- ZIP

t Change

t Addition

t DELETE

DOCUMENT # FEI # NAME STREET ADDRESS CITY - ST- ZIP

t Change

t Addition

t

DELETE

DOCUMENT # FEI # NAME STREET ADDRESS CITY - ST- ZIP

t Change

t Addition

8. I (we) the undersigned, being the sole (all the) party(ies) owning interest in the above fictitious name, certify that the information indicated on this form is true and accurate. I (we) understand that the signature(s) below shall have the same legal effect as if made under oath. I further certify that the names of individuals listed on this form do not qualify for an exemption contained in section 119, Florida Statutes. (At least one signature required)

Signature of Owner

Date

Email address: (to be used for future renewal notification)

MAKE CHECK PAYABLE TO DEPARTMENT OF STATE
FILING FEE $50.00

PLEASE READ ALL INSTRUCTIONS CAREFULLY BEFORE COMPLETING THE FORM. IF YOU NEED ASSISTANCE, PLEASE CALL (850) 245-6058. INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR RENEWAL
Block 1. Block is preprinted with the fictitious name, the registration number, and mailing address of the business as it was originally registered with this office. The name of the business cannot be changed on the statement of renewal. A cancellation/reregistration must be filed. Please call (850) 245-6058 for the appropriate form. Block 2. If the mailing address printed in block 1 is incorrect, enter the correct mailing address in block 2. This address does NOT have to be the principal place of business and can be directed to anyone's attention. DO NOT USE AN ADDRESS THAT IS NOT YET OCCUPIED. ALL FUTURE MAILINGS AND ANY CERTIFICATION REQUESTED ON THIS RENEWAL FORM WILL BE SENT TO THE ADDRESS IN BLOCK 1 OR AS CHANGED IN BLOCK 2. WE WILL NOT SEND CERTIFICATION TO ANY OTHER ADDRESS OR REDIRECT MAIL RETURNED TO THIS OFFICE. Block 3. Block is preprinted with the county of the principal place of business. "MULTIPLE" may be preprinted if more than one county was reported when original registration was filed; change if necessary. Block 4. Block is preprinted with the date filed in this office; if blank enter the correct file date, if known. Block 5. Should you desire a certificate of status, please check the box in block 5 and include an additional $10.00 with the filing fee. The certificate of status will be sent to address in block 1 or in block 2, if changed. Block 6. Block 6 contains the Fictitious Name owner(s), their addresses, document number and Federal Employer Identification Number (FEI) if applicable. (Due to space limitations only four owners are printed.) If there are additional owners, please list them on an attached sheet or in block 7 as additions. Do not make any changes in block 6 unless deleting an owner. Owners listed that are not individuals must be registered and active with this office or provide documentation as to why they are not required to register. Examples would be Federally Chartered Corporations or Legislatively created entities. NOTE: If the fictitious name indicated in block 1 contains the word(s) "corporation" or "incorporated", or the abbreviation "corp." or "Inc.", the owner(s) must be a corporation registered or incorporated with this state. Block 7. Block 7 is for changes or additions to the owners in block 6. Changes must be typed or printed in ink and legible. Owners that are not individuals must be registered and active with this office or provide documentation as to why they are not required to register. Examples would be Federally Chartered Corporations or Legislatively created entities. NOTE: If the fictitious name indicated in block 1 contains the word(s) "corporation" or "incorporated", or the abbreviation "corp." or "Inc.", the owner(s) must be a corporation registered or incorporated with this state. Block 8. This renewal must be signed in block 8 with an original signature by at least one owner that is listed in block 6, block 7 if a change, or on an attachment.

If this Application for Renewal of Fictitious Name is not filed on or before December 31, 2009, the fictitious name will be cancelled and removed from the records of the Department of State. This renewal application must be post-marked by December 31, 2009. After the Application for Renewal is filed, the effectiveness of the fictitious name registration is continued until December 31, 2014.
MAILING ADDRESS: Fictitious Name Renewal Division of Corporations Post Office Box 1300 Tallahassee, Florida 32302-1300 Internet Address: www.sunbiz.org Courier Service Address: Division of Corporations Clifton Building 2661 Executive Center Circle Tallahassee, Florida 32301

Phone Number: (850) 245-6058 Hearing/Voice Impaired may call (850) 245-6096 (TDD)

CR4E003 (5/09)