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This form may only be used to abandon a Placer County Fictitious Business Name. Statement that had been filed within the past five years.The statement shall be executed in the same manner as a fictitious business name statement and shall be filed with the county clerk of the county in which the. List the fictitious business name the entity would like to abandon. 4. List the date when the original fictitious business name statement was filed. 5. The form must be typed or legibly completed using BLACK INK only. APPLICABLE CALIFORNIA BUSINESS and PROFESSIONS CODE SECTIONS. Residence Address of 1st Registrant (P. Name of Registrant (Person, Corporation or LLC name). Professional association, or limited liability partnership registered with the secretary of state to transact business.