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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. ___________________________________________