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The undersigned individual, being the sole owner of {company name}, a {type of business} operating at {address}, attests that he/she will be operating said business under a fictitious or assumed name, beginning {date}.
There are no other partners or part owners of this business.
The assumed or fictitious name of the business will be {assumed or fictitious name}.
The undersigned certifies that this information is true and correct to the best of his/her knowledge.
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