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Application For Reinstatement

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NFP 112.45/113.60

FORM

(rev. Dec. 2003)

APPLICATION FOR REINSTATEMENT

DOMESTIC/FOREIGN CORPORATIONS

General Not For Profit Corporation Act

Secretary of State

Department of Business Services

501 S. Second St., Rm. 350

Springfield, IL 62756

217-782-5797

217-785-5782

Remit payment in the form of a cashier’s check,

certified check, money order or an Illinois

attorney’s or CPA’s check payable to Secretary

of State. DO NOT SEND CASH.

Filing Fee: $25

____________________________________ File #_____________________________

Approved: ___________

———— Submit in duplicate ———— Type or Print clearly in black ink ———— Do not write above this line ————

1. a. Corporate Name as of date of issuance of Certificate of Dissolution or Revocation:

____________________________________________________________________________________________

b. Corporate Name if changed (See Note 2 on back.): _________________________________________________

c. If a foreign corporation having authority to conduct affairs under an assumed corporate name restriction, the

Assumed Corporate Name (See Note 3 on back.):

____________________________________________________________________________________________

2. State of Incorporation: ____________________________________________________________________________

3. Date Certificate of Dissolution or Revocation was issued: ________________________________________________

4. Name and Address of Registered Agent and Illinois Registered Office upon reinstatement:

Registered Agent: _______________________________________________________________________________

First Name

Middle Name

Last Name

Registered Office: _______________________________________________________________________________

Number

Street

Suite # (P.O. Box alone is unacceptable)

Registered Office

_______________________________________________________________________________

City

ZIP Code

County

NOTE: completion of Article 4 does not constitute a registered agent or office change. (See Note 4 on back.)

5. This application is accompanied by all delinquent reports together with the filing fees and penalties required. (See Note

1 on back.)

6. The undersigned corporation has caused this application to be signed by a duly authorized officer, who affirms, under

penalties of perjury, that the facts stated herein are true.

All signatures must be in BLACK INK.

Dated _______________________________ , _____

________________________________________________

Month

Day

Year

Exact Name of Corporation

______________________________________

Any Authorized Officer’s Signature

______________________________________

Name and Title (type or print)

Printed by authority of the State of Illinois. January 2015 - 1 - C 219.13

Application For Reinstatement

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