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MINNESOTA SECRETARY OF STATE

AMENDMENT TO CERTIFICATE OF ASSUMED NAME
Minnesota Statutes Chapter 333 Read the instructions before completing this form.

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Filing Fee: $25.00

The filing of an assumed name does not provide a user with exclusive rights to that name. The filing is required for consumer protection in order to enable consumers to be able to identify the true owner of a business. PLEASE TYPE OR PRINT LEGIBLY IN BLACK INK FOR RECORDING PURPOSES. 1. State the exact assumed name under which the business is or will be conducted: (one business name per application) ___________________________________________________________________________________________________ 2. State the address of the principal place of business. ___________________________________________________________________________________________________ Street City State Zip code (A complete street address or rural route and rural route box number is required; the address cannot be a P.O. Box.) 3. List the name and complete street address of all persons conducting business under the above Assumed Name, OR if an entity, provide the legal corporate, LLC, or Limited Partnership name and registered office address. Attach additional sheet(s) if necessary. Name (please print) Street City State Zip

___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ 4. This certificate is an amendment of Certificate of Assumed name number ______________________originally filed on ________________________ under the name ______________________________________________________________ (List the previous name only if you are amending that name.) 5. I certify that I am authorized to sign this certificate and I further certify that I understand that by signing this certificate, I am subject to the penalties of perjury as set forth in Minnesota Statutes section 609.48 as if I had signed this certificate under oath.

________________________________________________________________ Signature (ONLY one person listed in #3 is required to sign.) _____________________ Date ________________________________________________________________ Print Name and Title ________________________________________________________________ Contact Person Daytime Phone Number
bus40 Amendment to Certificate of Assumed Name Rev. 5-07

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INSTRUCTIONS
THIS FORM MUST BE TYPEWRITTEN OR PRINTED IN BLACK INK. State law requires that this Certificate of Assumed Name be filed and published prior to the conduct of any business. Licensing and regulatory boards as well as private vendors and banks often require proof of the filing of this Certificate before issuing licenses, permits or entering into business relationships with the business. If any of the information on the most recently filed Certificate or Amended Certificate of Assumed Name changes, you must file this Amended Certificate within 60 days. 1) State the exact business name (new name if changing name) on line 1. Only one business name may be filed per form. Assumed names that duplicate corporate, limited partnership, limited liability partnership, limited liability company names or trademarks already on file cannot be accepted for filing. Call the Business Information Line of the Office of the Secretary of State at (651)296-2803 for a preliminary determination whether the assumed name can be filed. This will reduce the possibility of rejection of the Certificate and will provide for faster filing of this Certificate. You may only use corporate or other business entity designations if the business owner is a corporation or other business entity already entitled to use that designation. 2) State a complete street address or rural route and rural route box number of the principal place of business in Minnesota. A post office box cannot be accepted as the address of the principal place of business. If you have no business address in Minnesota, please state that on the application in item 2 and list the out-of-state address. 3) List the name and complete street address of all persons conducting business under the assumed name. If the business owner is a business organization such as a corporation, limited liability company, or limited partnership doing business under an assumed name, the legal name and registered office address is required. 4) List the original Certificate of Assumed Name number, the date on which the original was filed and, if you are changing the name in item 1, the original name. Refer to your original assumed name for this information. 5) Complete line 5 with the date, the signature of one person listed in #3, the printed name of the person signing and the title of the signer. Please print the name and daytime phone number of the person this office should contact if there are any questions about this form. 6) Filing Fee: $25.00 Payable to the MN Secretary of State. FILE IN-PERSON OR MAIL TO: Minnesota Secretary of State - Business Services Retirement Systems of Minnesota Building 60 Empire Drive, Suite 100 St Paul, MN 55103 (Staffed 8:00 - 4:00, Monday - Friday, excluding holidays) To obtain a copy of a form you can go to our web site at www.sos.state.mn.us , or contact us between 9:00am to 4:00pm, Monday through Friday at (651) 296-2803 or toll free 1-877-551-6767. 7) The Certificate of Amended Assumed Name must be published after filing for two consecutive issues in the legal notices section of a qualified legal newspaper in the county where the principal place of business is located. The newspaper will return an affidavit of publication a copy of the published notice which should be kept by the assumed name holder with the Certificate of Assumed Name. Failure to publish may render the Certificate of Amended Assumed Name Invalid. 8) Any changes due to a change of business name, address, ownership, or owner's address, require the filing of a Certificate of Amended Assumed Name form. The Certificate of Amended Assumed Name form must be filed within 60 days after any change has occurred and must be published as described in paragraph 7 above.

All of the information on this form is public. Minnesota law requires certain information to be provided for this type of filing. If that information is not included, your document may be returned unfiled. This document can be made available in alternative formats, such as large print, Braille or audio tape, by calling (651)296-2803/voice. For a TTY/TTD (deaf and hard of hearing) communication, contact the Minnesota Relay Service at 1-800-627-3529 and ask them to place a call to (651)296-2803. The Secretary of State's Office does not discriminate on the basis of race, creed, color, sex, sexual orientation, national origin, age, marital status, disability, religion, reliance on public assistance or political opinions or affiliations in employment or the provision of service.