Free Fillable Certificate of Discontinuance of Assumed Name Form - New York

New York State Department of State Division of Corporations, State Records & UCC One Commerce Plaza, 99 Washington Avenue Albany, NY 12231 www.dos.state.ny.us

CERTIFICATE OF DISCONTINUANCE OF ASSUMED NAME OF
(Insert Name of Entity)

Under Section 130 of the General Business Law

FIRST: The name of the entity is:
New York State is:

.

SECOND: Foreign entities only. If applicable, the fictitious name the entity agreed to use in THIRD: If the name of the entity is different on the last Certificate of Assumed Name or

Certificate of Amendment of Certificate of Assumed Name, the previous name of the entity is:

FOURTH: The present assumed name is: FIFTH: The date the original Certificate of Assumed Name was filed is: SIXTH: The date, if applicable, the last Certificate of Amendment of Certificate of Assumed
Name was filed is: .

SEVENTH: The date on which the discontinuance of assumed name occurred or the reason for
the discontinuance of the use of the assumed name:

.
DOS-1625 (Rev. 4/08)

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INSTRUCTIONS FOR SIGNING: If a corporation, by an officer; if a limited partnership, by a

general partner; if a limited liability company, by a member or manager; or by an authorized person or attorney-in- fact for such corporation, limited partnership or limited liability company. If the certificate is signed by an attorney-in-fact, include the name and title of the person for whom the attorney-in-fact is acting. (Example, John Smith, attorney-in-fact for Robert Johnson, president.)

Name of Signer

Signature

Title of Signer

CERTIFICATE OF DISCONTINUANCE OF ASSUMED NAME OF
(Insert Name of Entity)

Under Section 130 of the General Business Law

Filer's Name: Address: City, State and Zip Code:

Note: This form was prepared by the New York State Department of State. You are not required to use this form. You may draft your own form or use forms available at legal stationery stores. The Department of State recommends that all documents be prepared under the guidance of an attorney. The certificate must be submitted with a $25 fee. For Office Use Only

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