INSTRUCTIONS: STATEMENT OF RESERVATION OF NAME (Sample)

This form is only a sample.  The applicant cannot submit this form to the Secretary of State, but the form does serve as a template.  An attorney should help an applicant write the Statement of Reservation.  After the Statement of Reservation of Name is submitted and approved by the Secretary of State, the name will be reserved for 120 days. 

“Statement of Reservation of Name (Sample) Step 1”

In part 2, provide the proposed name of the company.  Make sure to review rules of names for corporations, partnerships, and limited liability companies. 

“Statement of Reservation of Name (Sample) Step 2”

Use part 3 if any of the restricted words are used within the entity’s name, the true name of the entity, or the trade name or trademark.  Check the appropriate box if applicable. 

“Statement of Reservation of Name (Sample) Step 3”

Provide the full name of the applicant in part 4.  If a business organization is filing a Statement of Reservation of Name, leave the first line blank and fill in the name of the business organization. 

“Statement of Reservation of Name (Sample) Step 4”

In part 5, provide the mailing address of the applicant or business organization.  Provide a street name or post office box information on the first two lines.  Provide the city, state, and zip code on the third set of lines.  If the business is foreign, provide a province (if applicable) and country on the fourth set of lines. 

“Statement of Reservation of Name (Sample) Step 5”

Provide the full name and address of the person delivering this form to the Secretary of State in part 6.  The perjury notice below part 5 applies to the person delivering or mailing this form as well.  An additional form may be attached in order to list other individuals responsible for delivering this form. 

“Statement of Reservation of Name (Sample) Step 6”

Make sure to review this document with your attorney.  The applicant will have to provide their signature at the bottom of the form, and the attorney will have to provide their name, bar information, and contact information at the bottom of the form as well.