Form Llc-5.48 - Petition For Refund
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Illinois
FILE #
LLC-5.48
Form
Limited Liability Company Act
This space for use by Secretary of State.
May 2012
Petition for Refund
Secretary of State
Department of Business Services
Limited Liability Division
SUBMIT IN DUPLICATE
501 S. Second St., Rm. 351
Type or print clearly.
Springfield, IL 62756
217-524-8008
This space for use by Secretary of State.
Filing Fee: $15
Payment may be made by check
Approved:
payable to Secretary of State. If
check is returned for any reason this
filing will be void.
1. Limited Liability Company Name: ___________________________________________________________________
2. State of Organization: ____________________________________________________________________________
3. Amount of Claim: ________________________________________________________________________________
No refund shall be made from an overpayment of less than $200.
Any amount to be refunded shall be reduced by $200.
4. Details of Transaction and all facts upon which the petitioner relies:
(If there is not sufficient space to cover this point, attach additional sheets of this size.)
5. I affirm, under the penalties of perjury, having the authority to sign hereto, that this penalty form is to the best of my
knowledge and belief, true, correct and complete.
Date: _________________________, ___________
Year
Month/Day
________________________________________
Signature
________________________________________
Name and Title (type or print)
________________________________________
If applicant is a Company or other Entity, state Name of Company
and indicate whether it is a member or manager of the LLC.
Printed by authority of the State of Illinois. May 2012 — 1 — LLC 35.4
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