Registration of Fictitious Name
(Sec. 417.200-417.230, R.S.Mo., 1978)
TO BE FILED IN DUPLICATE
THE FILING FEE OF $2.00 MUST ACCOMPANY THIS AFFIDAVIT. r P '
The affidavit must be signed and verified by all parties owning interest in the I
company. Mail with filing fee to: JAMES C. KIRKPATRICK, SECRETARY
OF STATE, P.O. BOX 778, JEFFERSON CITY, MISSOURI 65102. The
duplicate copy will be returned to the business address of the business DEC .0 7 1984
registered unless you indicate otherwise in your cover letter.
Make check for $2.00 payable to the State Director of Revenue. Z91 SECRETARY e r feworluato . Of SIAM
This information is for the use of the public and gives no protection to the
name. There is no provision in this Chapter to keep another company or
corporation from adopting and using the same name.
We, the undersigned, are doing business under the following name, and at the following address:
Business Address (Mo., if any; if not, other). 306 West Jackson St.
corporation of The ownership parties name having need and percentage an not interest be owned) listed: in the business, If all and parties the percentage are jointly they own and are severally (if a corporation liable, is owner, percentage indicate
Jimmy D. Davolt (Ind.) 306 West Jackson St. Bolivar MO 100
STATE OF MISSOURI
JAMES C. KIRKPATRICK, Secretary of State
CORPORATION DIVISION
No. X 1 Os 17."
Name to be registered. BROWN INSURANCE AGENCY (Effective Jan. 1, 1985)
City, State, and Zip Code. Bolivar, Missouri 65613
Name of Owners, Street and Number City State Percentage
Individual or of ownership
Corporate must equal
If listed,
100%
Corp. 56 (1-84) (Over)
. ,
Bolivar,
Missouri
306 West Jackson St.
65613
BROWN INSURANCE AGENCY
$2.00
MISSOURI
Registration of Fictitious Name
JEFFERSON CITY,
MISSOURI
P.O. BOX 778,
65102.
JAMES C. KIRKPATRICK, JAMES C. KIRKPATRICK,
Secretary of State SECRETARY OF STATE,
Bolivar
MO
306 West Jackson St.
(Ind.) Jimmy Davolt D.
100