Free 30353.FH11 - Indiana

CERTIFICATE OF ASSUMED BUSINESS NAME (All Entities)
State Form 30353 (R12 / 10-06) Approved by State Board of Accounts 2002

TODD ROKITA SECRETARY OF STATE CORPORATIONS DIVISION 302 W. Washington St., Rm. E018 Indianapolis, IN 46204 Telephone: (317) 232-6576

INSTRUCTIONS: Use an 8 1/2 x 11 sheet of white paper for attachments. Present original and one (1) copy to address in upper right corner of this form. Please TYPE or PRINT. Please visit our office on the web at www.sos.in.gov.
1. Name of entity

FILING FEES PER CERTIFICATE: For-Profit Corporation, Limited Liability Company, Limited Partnership $30.00 Not-For-Profit Corporation $26.00
2. Date of incorporation / admission / organization

3. Address at which the entitiy will do business or have an office in Indiana. If no office in Indiana, then state current registered address (street address) City, state and ZIP code 4. Assumed business name(s)

5. Principal office address of the entity (street address) City, state and ZIP code 6. Signature of officer or other authorized party 7. Printed name and title

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