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Certificate of Ownership of A Business: For Additional Owners, Please Complete The Back

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Certificate # _________________

GARY A. KING
DU PAGE COUNTY CLERK
P.O. BOX 1028
421 North County Farm Road
Wheaton, Illinois 60187
(630) 407-5500

CERTIFICATE OF OWNERSHIP OF A BUSINESS

NAME OF BUSINESS
ADDRESS OF BUSINESS
CITY, STATE & ZIP
NATURE OF BUSINESS
TELEPHONE NUMBER

The following is a true and full report of the names and addresses of all persons owning, conducting or transacting
the business named above.
NAME OF PERSON(S)

HOME ADDRESS

CITY, STATE, ZIP/PHONE

% OWNERSHIP

STATE OF ILLINOIS )
)SS
COUNTY OF DU PAGE)
I,
, being duly sworn upon oath, deposes and says that the
foregoing is a true and correct report of the real, full, name or names of the person or persons owning, conducting or
transacting the above-named business, with post office address or addresses.

Signed
Signed and sworn to (or affirmed) by _________________________________ before me on this_______ day
of ___________________ A.D. 20 ___.

For additional owners, please complete the back.

Notary Public or County Clerk

Fee $10.00
Upon filing this Certificate, it will be assigned a number. You will be given instructions on how to proceed with legal
publication, as required by law.

STATE OF ILLINOIS

)
)SS
COUNTY OF DU PAGE)
I,
, being duly sworn upon oath, deposes and says that the
foregoing is a true and correct report of the real, full, name or names of the person or persons owning, conducting or
transacting the above-named business, with post office address or addresses.

Signed

Signed and sworn to (or affirmed) by _________________________________ before me on this_______ day


of ___________________ A.D. 20 ___.

Notary Public or County Clerk

STATE OF ILLINOIS )
)SS
COUNTY OF DU PAGE)
I,
, being duly sworn upon oath, deposes and says that the
foregoing is a true and correct report of the real, full, name or names of the person or persons owning, conducting or
transacting the above-named business, with post office address or addresses.

Signed

Signed and sworn to (or affirmed) by _________________________________ before me on this_______ day


of ___________________ A.D. 20 ___.

Notary Public or County Clerk

STATE OF ILLINOIS )
)SS
COUNTY OF DU PAGE)
I,
, being duly sworn upon oath, deposes and says that the
foregoing is a true and correct report of the real, full, name or names of the person or persons owning, conducting or
transacting the above-named business, with post office address or addresses.

Signed

Signed and sworn to (or affirmed) by _________________________________ before me on this_______ day


of ___________________ A.D. 20 ___.

Notary Public or County Clerk

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