Filing Fee $25.00
NONPROFIT CORPORATION
STATE OF MAINE
STATEMENT OF INTENTION
_____________________
TO CARRY ON ACTIVITIES UNDER
Deputy Secretary of State
AN ASSUMED OR FICTITIOUS NAME
A True Copy When Attested By Signature
_____________________
______________________________________
Deputy Secretary of State
(Real Name of Corporation)
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)