MARY B. BEDARD, CPA
AFFIDAVIT OF IDENTITY – FICTITIOUS BUSINESS NAME STATEMENT
In accordance with Section 17913 of the CA Business and Professions Code, the following identifying information is required to
file a Fictitious Business Name Statement.
This certificate must be signed in the presence of a Notary Public (mail/drop-off) OR Deputy County Clerk (in person).
Name of Business
_, declare under penalty of perjury under the laws of the State of California,
that I am the registrant and intend to file this Fictitious Business Name. I understand that if I willfully make a false statement on
this affidavit, I may be punished by a fine not to exceed one thousand dollars ($1,000).
Signed on this
day of ________