Assumed Business Name Form

                                    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 ADAMS

NAMEOFBUSINESS:___________________________________________________________

NATURE OF BUSINESS:________________________________________________________

ADDRESS OF BUSINESS:_____________________________________________________

PRINTED NAMES AND RESIDENCES OF MEMBERS OF BUSINESS: ___________________________at________________________________________________

____________________________at_______________________________________________

___________________________at________________________________________________

___________________________at________________________________________________

FORM PREPARED BY: ________________________________________________________

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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 is true.

_______________________________ __________________________ __________________ Member's Signature                                   Printed Name                                      Capacity

Subscribed and sworn to before me, this _______ day of _________________, _________

______________________________ _________________________ ___________________ Signature of Notary/Recorder               Printed Name                                 County of Residence

(Notaries Only) My Commission Expires ______________________________

Filed on ___________________________, _________, Adams County Recorder

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