Free MNPCA-5 - Maine

Filing Fee $25.00

NONPROFIT CORPORATION STATE OF MAINE

STATEMENT OF INTENTION TO CARRY ON ACTIVITIES UNDER AN ASSUMED OR FICTITIOUS NAME

_____________________ Deputy Secretary of State

A True Copy When Attested By Signature

______________________________________
(Real Name of Corporation)

_____________________ Deputy Secretary of State

Pursuant to 13-B MRSA §308-A, the undersigned corporation executes and delivers the following Statement of Intention to Carry on Activities Under an Assumed or Fictitious Name: FIRST: The address of the registered office of the corporation in the State of Maine is ________________________________ ______________________________________________________________________________________________.
(street, city, state and zip code)

SECOND:

("X" one box only.) assumed name (13-B MRSA §308-A.1) fictitious name (13-B MRSA §308-A.2)

The corporation intends to carry on activities under the assumed or fictitious name of ______________________________________________________________________________________________. Please note: A fictitious name is a name adopted by a foreign corporation authorized to carry on activities in this State because its real name is unavailable pursuant to 13-B MRSA §301-A. Complete the following if applicable: THIRD: If such assumed name is to be used at fewer than all of the corporation's places of activity in this State, the location(s) where it will be used is (are): ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________

FORM NO. MNPCA-5 (1 of 2)

FOURTH:

(Foreign Corporation Only) Jurisdiction of incorporation ______________________________________________________ and the date on which the corporation was authorized to carry on activities in Maine _____________________________________________

DATED _________________________

*By ___________________________________________________
(signature)

__________________________________________________
(type or print name and capacity)

*By ___________________________________________________
(signature)

__________________________________________________
(type or print name and capacity)

*This document MUST be signed by any duly authorized officer. (13-B MRSA §104.1.B) Please remit your payment made payable to the Maine Secretary of State.

SUBMIT COMPLETED FORMS TO: CORPORATE EXAMINING SECTION, SECRETARY OF STATE, 101 STATE HOUSE STATION, AUGUSTA, ME 04333-0101 FORM NO. MNPCA-5 (2 of 2) Rev. 9/16/2005 TEL. (207) 624-7752