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 INDIANA,  COUNTY OF _____________________________
 
 
NAME OF BUSINESS:______________________________________________________
 
 
NATURE OF BUSINESS:____________________________________________________
 
 
ADDRESS OF BUSINESS:___________________________________________________
 
 
PRINTED NAMES AND RESIDENCES OF MEMBERS OF BUSINESS:
 
____________________  at ___________________________________________
 
____________________  at  __________________________________________
 
____________________  at  __________________________________________
 
____________________  at  __________________________________________
 
 
FORM PREPARED BY:__________________________________________
 
 
 
SECTION TO BE COMPLETED BY/IN PRESENCE OF NOTARY PUBLIC OR COUNTY RECORDER
 
I hereby certify that I have personal knowledge of the facts stated above
and that each of them are true.
 
 
______________________     ______________________    ____________________
Member's Signature              Printed Name                Capacity
 
 
 
Subscribed and sworn to before me, this _____ day of ____________, 20___.
 
 
 
_______________________   ________________________   ____________________
 
Signature of Notary/Recorder        Printed Name       County of Residence
 
 
(Notaries only) my commission expires __________
 
Filed on _________________________, 20_____.  _________________, Recorder